SAMPLE SART CONFIDENTIALITY FORMS
Multidisciplinary Team Confidentiality Agreement
The mission of the Multidisciplinary Teams (MDT) Coordinated by AGENCY NAME is to
conduct full reviews of sexual abuse, exploitation and/or neglect allegations and to develop effective and
efficient responses.
As an MDT participant, other agencies may inform me of confidential client information. The
purpose for the disclosure of this confidential client data is to ensure that appropriate social services,
legal services, and medical care is obtained for sexual assault victims and that allegations of abuse are
investigated and alleged abusers are prosecuted.
I understand that information contained in or other agencies records are designated as confidential
pursuant to the laws and regulations of the State of Georgia, and its implementing regulations and shall
not be disclosed by me to any person, organization, agency or other entity except as authorized or as
required for the purposes of a criminal investigation and/or prosecution or as otherwise required by law.
I agree that such information may not be used for any purpose other than the purposes stated in this
agreement and that any other use or release to any party of such confidential information or records
without prior written consent, will be presumed to be a breach of this Confidentiality Agreement. I
further agree that any breach of confidentiality may result in the referral of the matter to an appropriate
enforcing entity for potential sanctions.
**If I am a visitor coming into the meeting to observe the MDT, I agree to all of the above-stated
conditions in this Confidentiality Agreement. I also agree that I shall be treated in the same manner as the
members of the MDT and will be subject to this Agreement in the same manner and to the same extent
as the members of the MDT.
I the undersigned, as a representative of the agency listed below and member or visitor of the MDT,
agree that all information discussed and/or obtained in these case review meetings will remain
confidential other than for the reasons stated above. This Confidentiality Agreement will be renewed on
an annual basis.
__________________________ __________________________
Print Name Print Agency Name
Statement of Confidentiality
I agree to treat the identity of all identifying information about clients and other members of the AGENCY
NAME as well as the location and other identifying information about the shelter, and transitional houses
as confidential. Clients’ names will not be mentioned outside the structure of the program. Cases will not
be discussed with any person other than a AGENCY NAME staff, unless specifically authorized by the client.
Rationale for the Confidentiality Agreement: Each organization has an obligation to safeguard the
confidentiality of personal information and shall not disclose the identity of an individual or information
about a particular person without their consent. The policy of AGENCY NAME recognizes the rights of
individuals to privacy and conforms to the general principles defined by the Federal Privacy Act of 1974,
generally accepted social work practice and the guidelines of various professional associations. AGENCY
NAME believes this to be important for each employee and volunteer is expected to read, understand
and sign a confidentiality agreement before starting to work or volunteer.
The Principle of Client Confidentiality: The principle of confidentiality limits the disclosure of personal
information client served that is revealed (regarding clients) in a service (medical, counseling, legal)
relationship. Clients’ expect their information to be safeguarded within the service relationship.
Employee Name: ________________________________________________________________
Employee Address: ________________________________________________________________
(Street)
_______________________________________________________________
(Street)
_______________________________________________________________
(City, State, Zip)
Employee Signature: Date: