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!

Model Policy: Confidentiality, Privacy, and VAWA 2005 for Community-Based Domestic Violence/Sexual Assault Advocacy Programs

This model policy has sections addressing: general principles; a written agreement to maintain confidentiality; definitions including what constitutes confidential and personally identifying information; the prohibition to release information to anyone outside the agency (e.g. shelter address, staff and survivor information); protocols for releases of information; and possible exceptions to confidentiality including mandatory reporting. This policy is intended to be signed by all agency/program staff.

Agencies and innovative partnerships are encouraged to use and adapt this model policy. You may change wording to match the language your agency or partnership prefers (e.g. client, victim, survivor, service participant). To adapt the template simply:

  • add information relevant to your specific agency, partnership and funders;
  • insert your [program/agency/partnership/collaboration names] and letterhead; and,
  • remove generic template blue instruction notes and other notices.

Distribution Permissions: Published June 2008. May be reproduced or adapted for nonprofit or educational uses with acknowledgement of authors and/or publisher.

Request this Template: We do not post this template online, but you may request that we email it to you using our Request this Template Form.

This template is also available in Spanish. Please contact us here to request the Spanish version. (Select Safety Net/Technology Safety under Subject to ensure that it goes to the right team.)