Non-profit victim service agencies, advocates, and partnerships that provide services to survivors of domestic violence, dating violence, sexual assault and stalking may adapt these forms, policies and agreements for immediate use.  Use Step-by-step easy instructions!

Client Notice of Rights / Confidentiality Form

This form is used to provide upfront notice to each client about their rights and your practices, including your agency's information sharing and confidentiality protections and requirements, and their rights regarding the confidentiality of their personal information and communications.

Your agency and collaborative community response partners are encouraged to adapt and use this model form. 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).

This adaptable template form is available in: