Please review and sign.

1. CONFIDENTIALITY AGREEMENT
The Client is not authorized to release company-sensitive information learned during the course of their involvement
with the agency. The Client is not authorized to discuss or release information regarding child residents with anyone
who has not signed a confidentiality agreement as an employee, or who has no direct relation to a service being
provided for the child. The resident’s placement is strictly confidential, as well as information about the resident’s
reason for placement and/or family situation. Unauthorized release of information (whether written or verbal), including
but not limited to; information regarding the agency, its programs, finances, it’s intended course of action, contracts,
photos, donors, employees or residents is cause for termination.
The Client hereby understands that records, personal communications, and/or information received or learned by me in
the course of my responsibilities as a parent are strictly confidential. I understand that information contained within
employee files, contract files, donor files, resident files, etc. must not be divulged now or ever to any person who has
not signed this statement of understanding or without the authorization of the person or their legal representative to
who such information refers.
Names of children in placement shall not be released to anyone over the telephone that calls to inquire about a child.
The release of this information may only be approved by a Case Manager or the Program Director after receiving
written authorization for the release of information and/or appropriate court orders.
Photos of child residents may only be taken for individual use. A child’s photo may not be taken for media.
Furthermore, I understand Federal law mandates strict confidentiality concerning individuals that have AIDS or are HIV
Positive. The State of Texas enacted laws that comply with federal laws and regulations. Foster/ Adoptive Parent(s)
are expected to know these laws and implement the laws.
Section 81.046 and 81.103 of the Texas Health and Safety Code make the test results confidential and Section
81.103(j) makes violation of confidentiality a crime. The laws state that an adult individual who is HIV positive or has
AIDS (or his/her legal guardian) is the only person with the right to disclose this information with few exceptions. The
exceptions are:
 The spouse may be informed (81.103(b)(7));
 The Texas Department of Health must be informed (81.103(b)(91));
 Medical personnel, including emergency personnel giving medical services (81.103(b)(94) and 81.046).
 The legal guardian or managing conservator of a child found to be HIV positive or infected with AIDS may by
law (section 81.103(d) inform anyone. If TDPRS is not the managing conservator of the child, the agency
cannot disclose this information.
Prior to discussing either via verbal or written means any company-sensitive business (i.e. contract information,
contract status, financial status, financial information, trade secrets, donor information, telephone numbers of
employees, status of employees, etc.), The Client must obtain written permission from the Program Director.
The Client is not authorized to release photos or provide information to the press or anyone outside of the agency
without the prior authorization of the Program Director. All press inquiries should be forwarded to the Program
Director.
Latest Revision: 06/01/09 Page 1 of 2 file: CPA Policies/Forms/Parent Files/Confidentiality Agreement

2. This Confidentiality Agreement does not limit CPS or other state agency’s right of access to resident’s case records or
to other information relating to resident’s served under contract with CPS. CPS has an absolute right to access and
copy such information, upon request.
I clearly understand the seriousness of confidentiality and further understand that a violation of the confidentiality policy
for The Client could result in disciplinary action including, but not limited to termination.
THE CLIENT DATE
THE CLIENT DATE
Latest Revision: 06/01/09 Page 2 of 2 file: CPA Policies/Forms/Parent Files/Confidentiality Agreement