Full Disclosure Consent
What is your first and last name?
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It is important that you understand the benefits and limitations of a
Full Disclosure. If you have any concerns or questions, please discuss
them with your clinician.
Please read and agree to the following statements:
I am willingly participating in Full Disclosure.
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I am willingly participating in Full Disclosure.
I understand that Full Disclosure is does not guarantee honesty or sobriety.
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I understand that Full Disclosure is does not guarantee honesty or sobriety.
I understand that Full Disclosure does not guarantee my relationship will last.
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I understand that Full Disclosure does not guarantee my relationship will last.
I understand that Full Disclosure will likely activate challenging
emotions that include anger, confusion, fear, depression, anxiety and
other such emotions.
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I understand that Full Disclosure will likely activate challenging
emotions that include anger, confusion, fear, depression, anxiety and
other such emotions.
I have discussed concerns with my clinician.
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I have discussed concerns with my clinician.
I have a Post-Disclosure session in place.
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I have a Post-Disclosure session in place.
I agree to utilize my Post-Disclosure After Care Plan.
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I agree to utilize my Post-Disclosure After Care Plan.
I do not have a plan of suicide or harming myself.
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I do not have a plan of suicide or harming myself.
I do not have a homicidal plan of harming my partner or spouse or anyone else.
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I do not have a homicidal plan of harming my partner or spouse or anyone else.
If I feel that this changes (suicide or homicide) Post-Disclosure, or
feel that I am a danger to myself, my partner, my children, or others, I
will call 911 and my clinician immediately.
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If I feel that this changes (suicide or homicide) Post-Disclosure, or
feel that I am a danger to myself, my partner, my children, or others, I
will call 911 and my clinician immediately.
I agree, Post-Disclosure, to contact 911, my clinician, and other safe supports if I feel I am at risk to myself or another.
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I agree, Post-Disclosure, to contact 911, my clinician, and other safe supports if I feel I am at risk to myself or another.
I agree not to abuse substances, sexually act out, or participate in risky self-harm behaviors Pre- or Post-Disclosure.
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I agree not to abuse substances, sexually act out, or participate in risky self-harm behaviors Pre- or Post-Disclosure.
I agree to arrive sober to Full Disclosure.
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I agree to arrive sober to Full Disclosure.
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 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.
I understand that should I disclose anything that falls into the limits
of confidentiality, my clinician is a mandated reporter and is legally
required to disclose this information to the proper authorities.
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I understand that should I disclose anything that falls into the limits
of confidentiality, my clinician is a mandated reporter and is legally
required to disclose this information to the proper authorities.
I agree to participate respectfully and to request a time-out if needed during Full Disclosure.
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I agree to participate respectfully and to request a time-out if needed during Full Disclosure.
If I am feeling overwhelmed, ill, or faint, I understand that I can ask to stop Full Disclosure.
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If I am feeling overwhelmed, ill, or faint, I understand that I can ask to stop Full Disclosure.
I agree to continue my program and to complete the other parts of Full
Disclosure, including the Impact Letter for my spouse/partner.
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I agree to continue my program and to complete the other parts of Full
Disclosure, including the Impact Letter for my spouse/partner.
I agree that I am not seeking a divorce at this time, and will not use
the information given by my recovering partner against him/her in a
lawsuit or custody should the relationship end.
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I agree that I am not seeking a divorce at this time, and will not use
the information given by my recovering partner against him/her in a
lawsuit or custody should the relationship end.
I understand that there is no way for my clinician to predict the outcome post-Full 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.
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I understand that there is no way for my clinician to predict the outcome post-Full 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.
I have had my questions answered regarding Full Disclosure and have done my preparation with my clinician. I am participating willingly and
understand that I can withdraw my participation at any time.
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I have had my questions answered regarding Full Disclosure and have done my preparation with my clinician. I am participating willingly and
understand that I can withdraw my participation at any time.