National Network to End Domestic Violence Official Website

escape this website SAFETY ALERT: If you are in danger, please use a safer computer, or call 911, a local hotline, or the U.S. National Domestic Violence Hotline at 1-800-799-7233 and TTY 1-800-787-3224. Learn more technology safety tips. There is always a computer trail, but you can leave this site quickly.

The National Network to End Domestic Violence. Click to return to the home page.

Text Size:

Action Alerts

Sign up for action alerts...

No More
WomensLaw

Content

 Print  Email

Client Notice of Rights / Confidentiality Form

This form may be used by agencies to provide upfront notice to each client (e.g. victim, survivor) about their rights and your practices. This includes your agency's information sharing and confidentiality protections and requirements, and, the client's rights regarding the confidentiality of their personal information and communications.

Instructions: Your agency and/or collaborative community response partners are permitted to adapt and use this model form in your work. To adapt this template for use, simply:

  1. add information relevant to your specific agency, partnership and funders;
  2. insert your [program/agency/partnership/collaboration names] and letterhead;
  3. remove any generic template blue instruction notes and other notices from us;
  4. if needed, minorly change certain words like victim to match the language your agency or partnership prefers (e.g. client, victim, survivor, service participant).
  5. add any additional rights that the client has and any additional obligations that your agency has.

Forms to download and minorly adapt for use:

This template form was created by The Confidentiality Institute in partnership with the Safety Net Project at the National Network to End Domestic Violence in 2008.