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Professional Disclosure Form - Private Sector Example - Forensic
You have been referred by _______ to receive a vocational assessment. The purpose of this assessment is to evaluate your ability to work. I will be providing an opinion regarding appropriate alternate employment, your wage earning capacity, return to work barriers, and recommendations to overcome such, if possible. I have been retained to provide an opinion only and I have not been retained to provide any services that I might recommend to expedite your return to work. In general, our meeting will be limited to this one time and I may be asked to testify in a legal proceeding regarding information obtained during your assessment and my opinion regarding your employability, wage earning capacity, and recommendations for dealing with any identified employment barriers. Your role is to provide accurate information in response to my questions. If you do not understand the reason for a particular question that I may ask, you have the right to request an explanation for such before responding. Depending upon the wishes of my referral source, I may or may not be providing a written report. You may wish to inquire of your attorney as to whether this report is available for your review. A benefit to you by virtue of undergoing this process is that an objective and unbiased opinion will be provided regarding your employability, if any, wage earning capacity, and barriers to employment.
Often, I involve other professionals on staff to assist me with various aspects of developing my opinion. Discussions regarding your case may be held with such individuals and possibly my supervisor.
I am a Certified Rehabilitation Counselor. Attached is a copy of my professional qualifications. Should you have any concerns please contact me. If you continue to have concerns, please contact my supervisor. If you believe that I have acted in an unethical manner, please contact the Commission on Rehabilitation Counselor Certification.
As this assessment is taking place within the context of legal action brought by you, it is important that you understand that any information that I receive from you or other sources during the course of this assessment and formulation of my opinion could be shared in my report, or, in a legal proceeding. The normal confidentiality considerations of a client-counselor relationship do not apply in this context. Besides these limits on confidentiality, these additional situations may require that I divulge information concerning you:
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If I become aware of any legal issues preventing your ability to be employed in any or all
branches of the labor market or to receive other vocational services. |
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If I believe that you are going to harm or endanger yourself or others, I am required to notify the endangered individual(s), the proper authorities and/or officials
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If I believe you are going to harm or endanger or abuse children or the elderly, I must report this to state or local authorities.
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Requests for information from other parties (i.e. doctors, physical therapists, your employer, etc.) involved in your case may occur. If so, you would have to sign a release of information form before your records could be released. That signature is voluntary.
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If this agency or I are sued or court ordered and a properly issued subpoena is received, then information in your file may be released.
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If you are a minor or not your own legal guardian, then the information in your file may be available to your legal guardian or advocate.
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There may be some risks involved in the vocational assessment process. You may not agree with my opinion and such may not be favorable to your case.
Before signing this form, I will review the following topics with you.
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My roles and responsibilities |
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Limitations on what I can do |
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Your roles and responsibilities |
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Legal issues affecting services |
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Confidentiality |
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Frequency and length of service |
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Nature and type of rehabilitation services provided |
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Risks and benefits involved with vocational rehabilitation services |
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Risks associated with electronic communication |
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Potential of my providing testimony in a court setting regarding your case |
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Records preservation |
By signing this form, I attest that I have discussed the aforementioned topics with the counselor and that I understand the information discussed as well as the information contained within this document.
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Signature of Client |
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Printed Name of Client |
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Signature of Legal Guardian |
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Printed Name of Legal Guardian |
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Signature of Counselor |
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Date |
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Printed Name of Counselor |
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Commission on Rehabilitation Counselor Certification. (2006). Professional Disclosure Form - Private Sector Example – Forensic. Retrieved [date] from, http://www.crccertification.com/pages/30code.html
This disclosure form is provided by the Commission on Rehabilitation Counselor Certification (CRCC) as a sample of the content that would be appropriate to include in a disclosure form for the forensic setting. The form must be reviewed for applicability to each particular caseand appropriate modifications must be made.
Developed 8/02 – Updated 8/06
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