New Client Notice

Kardia® Counseling & Consulting, PLLC will maintain sufficient records to justify thorough and appropriate treatment. The information you provide is confidential and release or disclosure of any identifiable information to any individual or agency is prohibited except under the following ethical and legal conditions:

  1. Client/legal representative has signed a valid authorization for release of information to a third party. (Informed Consent)
  2. Client is seeking treatment at a facility within the N. C. Division of Mental Health, D.D., and Substance Abuse Services, and it has been determined to be in the client’s best interest to disclose information to the facility where client is requesting services. (This excludes clients receiving substance abuse treatment.)
  3. In the interest of public safety. (It is determined by a clinical staff member that the client presents a danger to self or others.)
  4. In response to a court order by a judicial official.
  5. In response to a medical emergency.
  6. State and federal laws require reporting of child abuse, child neglect, disabled adult abuse, gunshot/knife wounds, and communicable diseases.
  7. In cases where spouse/elder abuse or neglect is disclosed in the course of treatment, this information may be reported to local protective services agencies; to include the Army Family Advocacy Program (pertains to Tricare beneficiaries).
  8. Crimes committed at Kardia® Counseling & Consulting, PLLC, crimes against an employee of the office, and any threat to commit such a crime.
  9. In the investigation of life-threatening threats to an elected official.

Alcohol and drug abuse records are confidential and protected by Federal law and regulations. It is a crime for this office to violate the Federal law and regulations. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Client data is maintained in a computerized system for financial, statistical, and program planning purposes. Only authorized staff members have access to this data.


Patient Signature:
Patient Signature Date:
Parent/Legally Responsible Person:

(if patient is below 18 years of age)
Parent Signature Date: