Confidentiality Agreement

Federal law guarantees privacy and confidentiality for children, families, and their records. As a visitor (parent, care giver, volunteer, etc.) at Empowered Sports and Fitness, LLC, you may under limited circumstances, have access to or observe a child/client or family enrolled in a program/group, receiving treatment, in a session, and or other student/client information while you are on site. Child/client/family information includes enrollment, group membership, related services, and any records, files, documents and other materials that contain personally identifiable information of any child/client/family. As a child/client/family enrolled in a program or receiving treatment from Empowered Sports and Fitness, LLC you and your treatment team will have access to the records, treatment plans, progress reports, etc. of your child/children. It is imperative that you not disclose or discuss any child/client/family information and operating procedures that you may observe, participate in/with, meet, and or observe while at Empowered Sports and Fitness, LLC to any unauthorized individuals. An unauthorized individual would be any person that is not currently an employee of Empowered Sports and Fitness, LLC, or an individual that does not have written consent from the parent/guardian of the client and Empowered Sports and Fitness, LLC. This includes but is not limited to doctors, other agencies, outside therapists, caregivers (nannies), extended family, members of the press, and lawyers.

In order to maintain the privacy rights of our clients and their families as well as the integrity of our practice and program we ask that as a parent/caregiver/visitor to Empowered Sports and Fitness, LLC, you agree to the following:

  1. I will not disclose or discuss with unauthorized individuals the identity, treatment, or records of any child/client/family treated by Empowered Sports and Fitness, LLC.
  2. I will provide written authorization and consent to an individual that I wish to have access my child/children’s records/information.
  3. I understand that Empowered Sports and Fitness, LLC can refuse to speak to an individual even if I provide written authorization, if they feel as though it jeopardizes the privacy and integrity of their clients/families and practice.
  4. I understand that only the treatment team (therapists/educators/fee for service providers) employed or contract by Empowered Sports and Fitness, LLC and Michael Shipper and Emily Kline will have access to my child/children’s records and information, unless I provide written consent.
  5. I will not discuss or reveal the identity of any other children/clients/families, the operating/treatment procedures, staff, contract employees, volunteers, and or fee for service providers from Empowered Sports and Fitness, LLC with anyone.
  6. I understand that questions about Empowered Sports and Fitness, LLC, and or previously defined confidential child/client/family information must be directed to Michael Shipper and Emily Kline.
  7. I must report any breach or suspected breach in confidentiality, immediately upon my discovery, Michael Shipper and Emily Kline.
  8. As the parent/caregiver/visitor, I am at Empowered Sports and Fitness to receive services in the contracted area of treatment and should only report on the student(s)/client(s) you are designated to treat/observe/support and no other related service or student(s)/client(s) in the classroom and or building.

I have read and understand the Empowered Sports and Fitness policies concerning confidentiality and nondisclosure of any information regarding children/client(s)/families, treatments, programs and or staff. I agree to maintain the confidentiality of all information obtained in the course of my child/children enrollment/treatment, but not limited to, financial, technical, or propriety information of Empowered Sports and Fitness, LLC as well as any personal and sensitive information regarding students/clients, parents, treatment, and employees.

I understand that inappropriate disclosure or release of any information is grounds for immediate termination of treatment/enrollment, without refund, and subject to legal action.

Confidentiality Agreement

Parent/Guardian Name(Required)