Client Consent for Clinical Formal Disclosure – Chicago Center for Sexual Wellbeing

SA Client Consent for Clinical Formal Disclosure

Please read and initial the following statements if you have discussed with your therapist and agreed to participate in Formal Disclosure; sign and date at the bottom:

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Client Name *

understand that Formal Disclosure is a part of the standard of care for sex addiction recovery

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I give consent and release to allow my partner or spouse to join me in my clinical session to facilitate Formal Disclosure and post-disclosure meetings

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I agree that my questions and concerns regarding Formal Disclosure have been answered by my therapist

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I understand that I am not required to participate in Formal Disclosure if I choose not to do so

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I have worked with a professional clinician, one who is licensed and certified to support my process of Formal Disclosure

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I have been given materials, prep sheets, instructions, reading recommendations, and a careful process of preparation and support by my therapist

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I have the support of a sponsor, 12-step group, and other safe supports in place

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I agree to contact 911, my therapist and other safe supports if I feel I am at risk to myself or another post-disclosure

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I agree not to abuse substances or participate in risky self harm behaviors pre or post-disclosure, including sexually acting out

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I agree to arrive sober to Formal Disclosure

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I agree to take a polygraph as part of Formal Disclosure if my partner/spouse requests this

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I understand the limits of confidentiality (child abuse, downloading producing or watching child pornography, elder abuse, dependent adult abuse) as outlined in my initial client intake and informed consent forms

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I understand that should I disclose anything that falls into the limits of confidentiality, my therapist is a mandated reporter and is legally required to disclose this information to the proper authorities

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I agree to be responsible for any additional fees (this would include adjunct professionals, longer sessions, materials as needed) as part of the Formal Disclosure process

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I agree to participate respectfully and to request a time-out if needed during Formal Disclosure

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If I am feeling overwhelmed, ill, or faint, I understand that I can ask to stop Formal Disclosure

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I agree to drive separately, and if I am feeling as if I may need someone to drive me due to anxiety, I will discuss this with my spouse/partner and we will decide on a safe person to drive me

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I agree to continue my therapy and to complete the other parts of Formal Disclosure, including the Emotional Restitution (letter of apology) for my spouse/partner and meeting

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I agree to alert my therapist if I am feeling at risk for suicide or homicide

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I understand that there is no way for my therapist to predict the outcome post-Formal Disclosure. Possible outcomes may include: separation, divorce, impact on emotional well being, challenging feelings, law suits, public or private exposure, loss of respect and trust by spouse

Client Signature *

Date *

FOR YOUR OWN SAFETY, AND IN ORDER FOR YOUR THERAPIST TO BEST SUPPORT YOU DURING FORMAL DISCLOSURE, PLEASE RETURN THESE FORMS TO YOUR THERAPIST 1-WEEK PRIOR TO YOUR FORMAL DISCLOSURE DATE. FORMAL DISCLOSURE WILL NOT CONTINUE WITHOUT THESE FORMS IN PLACE.