Release of Information

As part of Surrogate Partner Therapy, I understand that the collaborating Therapist and Surrogate will be in contact between each session to ensure that decisions about the progression of surrogate partner sessions are fully informed.

Open communication with the Therapist, , is granted and will include full details of every session with the surrogate partner. Communications will include phone calls for verbal collaboration, as well as supervision notes, which the surrogate partner will provide to the clinician after each surrogate partner session.
Please note that supervision notes, also known as process recordings, document and analyze the contents of client sessions including hypotheses to be explored moving forward. Therefore these notes are separate from the client’s general record and not able to be requested by the client. Should a client desire a record of their progress by session, a running progress note can be provided by request.
I understand that the surrogate partner will not share any of my personal or identifiable therapeutic information with anyone else unless I name them here.

Additionally, I give permission for the surrogate partner to share information with (Optional):

Name:
Relation:
Contact phone/email:
Information to be shared includes (initial to indicate permission):
Basic information about SPT structureGeneral information about my progress, goals, and challengesAll details about my work with surrogate partnerSurrogate partner may also ask questions of this person about my history or background

My Full Name

Signature:

Release of Information

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