APPENDIX B

SAMPLE WAIVER OF CONFIDENTIALITY

New Hampshire Department of Corrections

Sexual Offender Treatment Program

Acknowledgement of Confidentiality Waiver

I,______________________________________, have been informed and do acknowledge that rights of confidentiality regarding my treatment in the Sexual Offender Program do not apply to actual, suspected or potential incidents of escape, suicidal or violent behavior. I have been informed that these will be reported to the appropriate authorities and to any potential victims.

I understand that sexual assault is a criminal offense with serious consequences to the victim and the community. I have been informed that New Hampshire law (RSA 169-C:29) requires any therapist or staff member to report to the appropriate authorities, including but not limited to Division of Children, Youth & Families (DCYF); Local Police; State Police; County Attorneys’ Office and Division of Field Services, any actual or suspected abuse or neglect of a specifically identifiable victim, regardless of how the staff member gains knowledge or such event.

I understand that the clinical staff will be reviewing Pre-Sentence Investigations (PSI), victim statements, police reports and previous evaluations to gain information that will assist me in my treatment program. Family members, prosecutors, victim witness coordinators and anyone who can provide information regarding my offending history may also be contacted.

I understand that my counselors and other staff are members of the Sexual Offender Treatment Team and that information will be shared regarding my progress and presence in treatment. Progress reports, maintenance contracts, risk assessments and treatment recommendations may be shared with Department of Corrections personnel. A Discharge Summary will be prepared upon termination or completion of the Sex Offender Program and will be part of my official offender record. The Discharge Summary may be released to the courts during any legal proceedings. Any outside person or treatment provider will need my signed Release of Information in order to obtain any written reports.

The purpose of my participation in the Sexual Offender Program is to learn how to control my sexual assaultive behavior. The primary responsibility of treatment providers is to assist me in this process, hold me fully accountable for my behavior and to enhance public safety.

Signature of Inmate __________________________________ Date___________________

Therapist Signature __________________________________ Date___________________