Before we begin working together, please read this contract carefully and let me know if you have any questions before signing. Once you sign, it will constitute a binding agreement between us. Your consent for psychological services is voluntary. Psychotherapy can be discontinued by either of us at any time.
I am a licensed clinical psychologist and my education, training, and experience are in psychologically assessing and treating children, adolescents, and adults in individual, family, or group psychotherapy. About half of my clients are adults, and half are teens and kids. My license is regulated by the State of California Department of Consumer Affairs, Board of Psychology. If you have any questions about the status of my license or the practice of psychology, contact the Board of Psychology at www.psychboard.ca.gov or (916) 263-2699. Although I share a waiting room with Dr. Flynn (psychiatrist), my practice is not professionally affiliated with his practice (each of us is sole proprietor).
Therapy works best when it is regularly scheduled and attended. However, it is also important that we remain healthy. If you (or your child) have a fever, body aches, or chills in the last 48 hours, we can cancel, reschedule, or move to a secure video session. Please do not come into the office or waiting room. This policy is to keep ourselves and our community healthy. Please note that a minimum of 24 hours of notice is required for rescheduling or canceling an appointment. If for any reason other than a medical emergency, a session is canceled less than 24 hours prior, a full fee will be charged. Please note that insurance policies typically do not reimburse late cancellations and no-shows.
If you need to contact me between sessions, please leave a message on voicemail at (805) 383-0882. Messages are retrieved during daytime working hours Monday through Friday. If telephone contact is necessary outside of regular working hours due to an emergency, you may call my cell phone at (805) 469-8670. Although I try to return emergency calls within the hour, an immediate response is not guaranteed. It is recommended that you call your family physician, psychiatrist, or dial 911 for immediate care.
PAYMENT FOR SERVICES
Individual psychotherapy is charged at the rate of $180 per 45-minute hour unless it’s a court-ordered case ($200 per hour). This fee is charged for psychotherapy appointments as well as time spent for other agreed-upon professional services, such as report writing, classroom observations, meeting attendance, record review, document/record preparation, and telephone calls lasting longer than ten minutes in length. Due to the difficulty of legal involvement, there is a $2800 daily charge for preparation for and attendance to any legal proceeding. Other court-related charges are available upon request. You are expected to pay for professional services at each appointment. Upon request, a statement may be provided for you to bill your insurance company. You are responsible for evaluating his/her insurance coverage for mental health services. Please note that if payments are not made for services rendered, a collection agency may be retained.
I do not permit clients to carry a balance of more than two sessions. If you are unable to pay this balance, we will discuss whether it makes sense to pause your care or develop another strategy so that you can avoid incurring additional debt. Please let me know if any problem arises during the course of therapy regarding your ability to make timely payments. A grace period will be allowed with no late fee if payment is received by 6:00 pm the next business day. After 6 pm on the next business day, there will be a $20 charge for late payments made within the same week and a $30 charge the next business week. I expect you to remember to send your payment. I do not regularly send reminder emails.
I occasionally find it helpful to consult other professionals about a case. During a consultation, every effort is made to avoid revealing your identity. The consultant is legally bound to keep the information confidential. I will not reveal information from such consultations to you unless I believe it is important for progress.
All information disclosed during the session is confidential and may not be revealed to anyone without written permission, except where disclosure is required by law. Disclosure may be required in the following circumstances: where there is reasonable suspicion of child or elder/dependent adult abuse; where there is reasonable suspicion that the client presents a danger of violence to self or others; where the client is gravely disabled; when mental state is used as part of legal defense or accusation; or when pursuant to a legal proceeding. With written permission, the pertinent and required information may be released to the insurance company or designated third party to process a claim. Most insurance companies require that the client authorize me to provide a clinical diagnosis and, in some cases, copies of treatment records. Please be aware that I do not have control over what happens to records after their release to other parties.
THE THERAPY PROCESS
The outcome of psychotherapy is dependent on several factors. Most important is your comfort level in working with me and your commitment to the process both in and out of the session. Potential benefits of psychotherapy include gaining a better understanding of personal goals and values, improving relationships, and helping solve many kinds of problems. Studies show that most people who participate in psychotherapy believe that it helped them in some way. But, there are no guarantees as to what you will experience. Potential risks of psychotherapy include discussing feelings or thoughts that may be uncomfortable and making choices that result in unexpected outcomes.
Regarding your treatment with me, we will initially meet for one to three sessions to complete an intake. Once the intake is completed, I will give you initial impressions and recommendations for referral and treatment. I use a combination of psychodynamic and cognitive-behavioral treatment models. Methods are chosen with consideration of various factors, such as the presenting problems, your preferences, and relevant case characteristics. By the end of the evaluation, I will be able to offer you first impressions of what our work will include and a treatment plan to follow. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist or you and, if not, I will give you referrals to other practitioners whom I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we can discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.
You are also free to discuss your complaints about me with anyone you wish and you do not have any responsibility to maintain confidentiality about what I do that you don’t like since you are the person who has the right to decide what you want to be kept confidential. If you have a concern or complaint about your treatment, please talk with me about it. I will take your criticism seriously and respond with care and respect. If you believe that I’ve been unwilling to listen and respond, or that I have behaved unethically, you can contact the Board of Behavioral Science Examiners which oversees licensing, and they will review the services I have provided.
Board of Psychology
1625 North Market Street, Suite N-215 Sacramento, CA 95834 1-866-503-3221
Your records from in-person and any electronic form (text, email, videoconferencing) may be recorded and stored in my office file or electronically as part of my medical records. Consultations, test results, and disclosures will be held in confidence subject to state and/or federal law. Although you are ordinarily guaranteed access to your records and that copies of records of consultation(s) are available to you upon written request, if I, in the exercise of professional judgment, conclude that providing records could threaten the safety of a human being, myself, or another person, I may rightfully decline to provide them. If such a request is made and honored, please understand that you retain sole responsibility for the confidentiality of the records released to you and that you may have to pay a reasonable fee to get a copy.
ELECTRONIC COMMUNICATIONS & SOCIAL MEDIA POLICIES
Many common modes of screen communication put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.
I use text messaging only with your permission and only for scheduling purposes. That means text messages should be limited to setting and changing appointments. Please do not email or text me about clinical matters, because these are not secure. If you need to discuss a clinical matter, please call me so we can discuss it on the phone or wait so we can discuss it during your therapy session. If you choose to communicate with me by text messaging, be aware that all texts are retained in the logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any text messages I receive from you and any responses that I send to you may become a part of your legal record.
Although I have several professional social media platforms, I do not communicate with, or contact, my private practice clients through social media platforms like Twitter and Facebook. Also, if I discover that I have accidentally established an online relationship with you on my personal Facebook pager, I will cancel that relationship. This is because these types of casual social contacts can create significant security risks for you. If you have an online presence, there is a possibility that you may encounter me by accident. If that occurs and you are concerned, please discuss it with me. I believe that any communications with clients online have a high potential to compromise the professional relationship. Also, please do not try to contact me in this way. I will not respond and will terminate any online contact no matter how accidental.
I have descriptions of my professional services on the websites DrTracyBennett.com, GetKidsInternetSafe.com, VCPA, CSUCI, and Psychology Today, among others like Yelp and Google. You are welcome to access and review the information that I have on those websites. I created a web-based business www.GetKidsInternetSafe.com (GKIS). You are welcome to access and review the information that I have on that website. If you choose to participate in GKIS social media or purchase products like books, online courses, or webinars, you will be treated as if you are Unknown to me like any other GKIS customer. Be aware that in my blog articles I often discuss typical client situations to educate the public and offer calls to action for parents. I change names, genders, dates, and details to avoid personal information being revealed on a public forum. If you have any concerns or questions about that, please bring it up in session or on the telephone.
I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. In this day and age, there is an incredible amount of information available about individuals on the Internet, much of which may be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment.
Recently it has become fashionable for clients to review their health care providers on various websites. Unfortunately, mental health professionals cannot respond to such comments and ratings because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy.
Notice of Privacy Practices
The Federal Health Insurance Portability and Accountability Act (HIPAA) requires mental health professionals to issue this official Notice of Privacy Practices. This notice describes how information about you is protected, the circumstances under which it may be used or disclosed, and how you may gain access to this information. Please review it carefully.
For psychotherapy to be beneficial, it is important that you feel free to speak about personal matters, secure in the knowledge that the information you share will remain confidential. You have the right to the confidentiality of your medical and psychological information, and this practice is required by law to maintain the privacy of that information. This practice is required to abide by the terms of the Notice of Privacy Practices currently in effect and to provide notice of its legal duties and privacy practices with respect to protected health and psychological information. If you have any questions about this Notice, please contact the Privacy Officer at this practice.
Who Will Follow This Notice
Any health care professional authorized to enter information into your medical record, all employees, staff, and other personnel at this practice who may need access to your information must abide by this Notice. All subsidiaries, business associates (e.g., a billing service), sites, and locations of this practice may share medical information with each other for treatment, payment purposes, or health care operations described in this Notice. Except where treatment is involved, only the minimum necessary information needed to accomplish the task will be shared. Uses and Disclosures for Treatment, Payment, and Health Care I may use or disclose your Protected Health Information (PHI), for treatment, payment, and health care operations purposes. The following should help clarify these terms:
• PHI refers to information in your health record that could identify you. For example, it may include your name, the fact you are receiving treatment here, and other basic information pertaining to your treatment.
• Use applies only to activities within my office and practice group, such as sharing, employing, applying, utilizing, and analyzing information that identifies you.
• Disclosure applies to activities outside of my office or practice group, such as releasing, transferring, or providing access to information about you to other parties.
• Authorization is your written permission to disclose confidential health information. All authorizations to disclose must be made on a specific and required form.
• Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. For example, with your written authorization I may provide your information to your physician to ensure the physician has the necessary information to diagnose or treat you.
• Payment Your PHI may be used, as needed, in activities related to obtaining payment for your health care services. This may include the use of a billing service or providing you documentation of your care so that you may obtain reimbursement from your insurer.
• Health Care Operations are activities that relate to the performance and operation of my practice. I may use or disclose, as needed, your protected health information in support of business activities. For example, when I review an administrative assistant’s performance, I
may need to review what that employee has documented in your record.
Written Authorizations to Release PHI
Any other uses and disclosures of your PHI beyond those listed above will be made only with your written authorization unless otherwise permitted or required by law as described below. You may revoke your authorization at any time, in writing.
Uses and Disclosures without Authorization
The ethics code of the American Psychological Association, California State law, and the federal HIPAA regulations all protect the privacy of all communications between a client and a mental health professional. In most situations, I can only release information about your treatment to others if you sign a written authorization. This Authorization will remain in effect for a length of time you and I determine. You may revoke the authorization at any time unless I have taken action in reliance on it. However, there are some disclosures that do not require your Authorization. I may use or disclose PHI without your consent in the following circumstances:
• Child Abuse – If I have reasonable cause to believe a child may be abused or neglected, I must report this belief to the appropriate authorities.
• Adult and Domestic Abuse – If I have reason to believe that an individual such as an elderly or disabled person protected by state law has been abused, neglected, or financially exploited, I must report this to the appropriate authorities.
• Health Oversight Activities – I may disclose your PHI to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
• Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information by any party about your treatment and the records thereof, such information is privileged under state law, and is not to be released without a court order. Information about all other psychological services (e.g., psychological evaluation) is also privileged and cannot be released without your authorization or court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You must be informed in advance if this is the case.
• Serious Threat to Health or Safety – If you communicate to me a specific threat of imminent harm against another individual or if I believe that there is clear, imminent risk of injury being inflicted against another individual, I may make disclosures that I believe are necessary to protect that individual from harm. If I believe that you present an imminent, serious risk of injury or death to yourself, I may make disclosures I consider necessary to protect you from harm.
• Worker's Compensation – I may disclose PHI regarding you as authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
Certain categories of information have extra protections by law, and thus require specially written authorizations for disclosures.
• Psychotherapy Notes – I will obtain special authorization before releasing your
Psychotherapy Notes. "Psychotherapy Notes" are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your record. These notes are given a greater degree of protection than PHI.
• HIV Information – Special legal protections apply to HIV/AIDS-related information. I will obtain special written authorization from you before releasing information related to HIV/AIDS.
• Alcohol and Drug Use Information – Special legal protections apply to information related to alcohol and drug use and treatment. I will obtain special written authorization from you before releasing information related to alcohol and/or drug use/treatment. You may revoke all such authorizations (of PHI, Psychotherapy Notes, HIV information, and/or Alcohol and Drug Use Information) at any time, provided each revocation is in writing, signed by you, and signed by a witness. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, the law provides the insurer the right to contest the claim under the policy.
Patient’s Rights and Psychologist’s Duties Patient’s Rights:
• Right to Request Restrictions – You have the right to request restrictions on certain uses/disclosures of PHI. However, I am not required to agree to the request.
• Right to Receive Confidential Communications by Alternative Means – You have the right to request and receive confidential communications by alternative means and locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.)
• Right to Inspect and Copy – You have the right to inspect or obtain a copy of PHI in my records as these records are maintained. In such cases, I will discuss with you the process involved.
• Right to Amend – You have the right to request an amendment of PHI for as long as it is maintained in the record. I may deny your request. If so, I will discuss with you the details of the amendment process.
• Right to an Accounting – You generally have the right to receive an accounting of all disclosures of PHI. I can discuss with you the details of the accounting process.
• Right to a Paper Copy – You have the right to obtain a paper copy of the Notice of Privacy Practices from me upon request.
• I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
• I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
• If I revise my policies and procedures, I will notify you at our next session, or by mail at the address you provided me.
If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at this practice or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or discriminated against for filing a complaint.
If you have any questions about this Notice or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me:
Tracy S. Bennett, Ph.D.
340 Rosewood Avenue, Suite A, Camarillo, CA 93010 805-383-0882 email@example.com
TELEPSYCHOLOGY INFORMED CONSENT
In addition to in-session options, I offer individual, couples, and group psychotherapy services through telephone or secure video conferencing when we are not in the same location. Before we begin working together, please read this contract carefully and let me know if you have any questions before signing. Once you sign, it will constitute a binding agreement between us. Your consent for psychological services via telepsychology is voluntary. You can withdraw from services at any time. We may also agree to modify your service delivery as needed.
STATE LICENSING & TECHNOLOGY REQUIREMENTS
To participate in telepsychology with me, you must:
• Be a resident of and conferencing in the state of California, as my license as a clinical psychologist only covers me in California
• Be prepared to exchange private information via secure email (like signing and sending this Office policy & Informed Consent form and my Authorization for Release of Information Form)
• Be prepared to exchange private information (like medical history and personal information) via your telephone and/or screen device to my telephone and/or screen device for audio and/or video conferencing
• Have access to and know how to operate your telephone and/or screen device for audio and/or video conferencing (I’ll send you a link to click with instructions prior to your first telepsychology session)
SOFTWARE SECURITY PROTOCOLS
Please recognize that the interactive technologies used in telepsychology (I use Zoom) incorporate network and security protocols to protect the confidentiality of client health information and images transmitted via any electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. In rare instances, security protocols could fail, causing a breach of privacy of personal health information.
RISKS & LIMITATIONS OF TECHNOLOGY
• Although technology allows for greater convenience, there are risks in transmitting information over technology that include, but are not limited to breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. Please make sure you are in a private location for your session.
• Regardless of the sophistication of today’s technology, some information I would ordinarily get in an in-person consultation may not be available in a telepsychology consultation. By signing, you understand that such missing information could in some situations make it more difficult for her to understand your problems and to help you get better.
• By signing, you understand that telepsychology is a new delivery method for professional services, in an area not yet fully validated by research, and may have potential risks, possibly including some that are not yet recognized.
• There is a possibility that the technology will fail before or during a session, that the transmitted information in any form will be unclear or inadequate for proper use in the consultation(s), and that the information may be intercepted by an unauthorized person or persons.
• As a recipient of telepsychology services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with me.
• I will require you to designate an emergency contact. You will need to provide permission for me to communicate with this person about your care during emergencies.
• We will also develop a plan for what to do during mental health crises and emergencies and a plan for how to keep your space safe during sessions. It is important that you engage with me in the creation of these plans and that you follow them when you need to.
PRIVACY & LAWS & STANDARDS
• By signing, you verify that you are using your own equipment to communicate and not equipment owned by another, and specifically not using your employer’s computer or network. You are aware that any information you enter into an employer’s computer can be considered by the courts to belong to your employer and your privacy may thus be compromised.
• Please do not record video or audio sessions without my consent. Making recordings can quickly and easily compromise your privacy and should be done so with great care. I will not record video or audio sessions.
• The laws and professional standards that apply to in-person behavioral services also apply to telepsychology services. This document does not replace other agreements, contracts, or documentation of informed consent. All elements of this office policy and informed consent still apply.
• Any party engaged in treatment can discontinue treatment at any time.
• You do not have to answer any question that you feel is inappropriate. Any refusal to participate in the consultation(s) or use of technology will not affect your continued treatment by me.
• Please note that your diagnosis depends on information, and treatment depends on the diagnosis. If you withhold information, you assume the risk that a diagnosis might not be made or might be made incorrectly and your telepsychology-based treatment might be less successful than it otherwise would be.
RELEASE OF LIABILITY
I unconditionally release and discharge Dr. Tracy Bennett and her designees from any liability in connection with my participation in the remote consultation(s).
FINAL AGREEMENT FOR TELEPSYCHOLOGY TREATMENT OF SELF OR MINOR
By signing below, you show that you have carefully read and fully understood the policies described above. It also means that you authorize information related to your (and/or your child’s) behavioral health to be electronically transmitted in the form of images and data through an interactive video or telephone connection to and from Dr. Tracy Bennett. With this knowledge, you voluntarily consent to participate in the telepsychology consultation(s), including but not limited to any care, treatment, and services deemed necessary and advisable, under the terms described herein.
THERAPY WITH MINORS
(If this doesn’t apply to your treatment, simply sign and date at the bottom of this document)
Parent Authorization for Minor’s Mental Health Treatment
To authorize mental health treatment for your child, you must have either sole or joint legal custody of your child. If you are separated or divorced from the other parent of your child, please notify me immediately. I will ask you to provide me with a copy of the most recent custody decree that establishes custody rights of you and the other parent or otherwise demonstrates that you have the right to authorize treatment for your child. If you share legal custody, the other parent must provide authorization for treatment if there is no court order.
One risk of child therapy involves disagreement among parents and/or disagreement between parents and the therapist regarding the child’s treatment. If such disagreements occur, I will strive to listen carefully so that I can understand your perspectives and fully explain my perspective. We can resolve such disagreements, or we can agree to disagree, so long as this enables your child’s therapeutic progress. Ultimately, parents decide whether therapy will continue. If either parent decides that therapy should end, I will honor that decision, unless there are extraordinary circumstances. However, in most cases, I will ask that you allow me the option of having a closing session with your child to appropriately end the treatment relationship.
Individual Parent/Guardian Communications with Me
In the course of my treatment of your child, I may meet with the child’s parents/guardians either separately or together. Please be aware, however, that, at all times, my client is your child – not the parents/guardians nor any siblings or other family members of the child. If I meet with you or other family members in the course of your child’s treatment, I will make notes of that meeting in your child’s treatment records. Please be aware that those notes will be available to any person or entity that has legal access to your child’s treatment record.
Mandatory Disclosures of Treatment Information
In some situations, I am required by law or by the guidelines of my profession to disclose information, whether or not I have your or your child’s permission. I have listed some of these situations below.
Confidentiality cannot be maintained when:
Child clients tell me they plan to cause serious harm or death to themselves or somebody else, and I believe they have the intent and ability to carry out this threat in the very near future. I must take steps to inform a parent or guardian or others of what the child has told me and how serious I believe this threat to be and to try to prevent the occurrence of such harm. I may be required to inform the person who is the target of the threatened harm [and the police].
Child clients are doing things that could cause serious harm to them or someone else, even if they do not intend to harm themselves or another person. In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed.
Child clients tell me, or I otherwise learn that it appears that a child is being neglected or abused-- physically, sexually, or emotionally--or that it appears that they have been neglected or abused in the past. In this situation, I am [may be] required by law to report the alleged abuse to the appropriate state child-protective agency.
I am ordered by a court to disclose information.
Disclosure of Minor’s Treatment Information to Parents
Therapy is most effective when a trusting relationship exists between the psychologist and the client. Privacy is especially important in earning and keeping that trust. As a result, children need to have a “zone of privacy” where children feel free to discuss personal matters without fear that their thoughts and feelings will be immediately communicated to their parents. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy.
It is my policy to provide you with general information about your child’s treatment, but NOT to share specific information your child has disclosed to me without your child’s agreement. This includes activities and behavior that you would not approve of — or might be upset by — but that does not put your child at risk of serious and immediate harm. However, if your child’s risk-taking behavior becomes more serious, then I will need to use my professional judgment to decide whether your child is in serious and immediate danger of harm. If I feel that your child is in such danger, I will communicate this information to you.
Example: If your child tells me that he/she has tried alcohol at a few parties, I may keep this information confidential. If your child tells me that he/she is drinking and driving or is a passenger in a car with a driver who is drunk, I would not keep this information confidential from you. If your child tells me, or if I believe based on things I learn about your child, that your child is addicted to drugs or alcohol, I would not keep that information confidential.
Example: If your child tells me that he/she is having voluntary, protected sex with a peer, I would keep this information confidential. If your child tells me that, on several occasions, the child has engaged in unprotected sex with strangers or in unsafe situations, I will not keep this information confidential.
You can always ask me questions about the types of information I would disclose. You can ask in the form of “hypothetical situations,” such as: “If a child told you that he or she were doing ________, would you tell the parents?”
Even when we have agreed to keep your child’s treatment information confidential from you, I may believe that it is important for you to know about a particular situation that is going on in your child’s life. In these situations, I will encourage your child to tell you, and I will help your child find the best way to do so. Also, when meeting with you, I may sometimes describe your child’s problems in general terms, without using specifics, to help you know how to be more helpful to your child.
Disclosure of Minor’s Treatment Records to Parents
Although California law may give parents the right to see any written records I keep about your child’s treatment, by signing this agreement, you are agreeing that your child or teen should have a “zone of privacy” in their meetings with me, and you agree not to request access to your child’s written treatment records.
Parent/Guardian Agreement Not to Use Minor’s Therapy Information/Records in Custody Litigation When a family is in conflict, particularly conflict due to parental separation or divorce, it is very difficult for everyone, particularly for children. Although my responsibility to your child may require my helping to address conflicts between the child’s parents, my role will be strictly limited to providing treatment to your child. You agree that in any child custody/visitation proceedings, neither of you will seek to subpoena my records or ask me to testify in court, whether in person or by affidavit or to provide letters or documentation expressing my opinion about parental fitness or custody/visitation arrangements.
Please note that your agreement may not prevent a judge from requiring my testimony, even though I will not do so unless legally compelled. If I am required to testify, I am ethically bound not to give my opinion about either parent’s custody, visitation suitability, or fitness. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, I will provide information as needed, if appropriate releases are signed or a court order is provided, but I will not make any recommendation about the final decision(s). Furthermore, if I am required to appear as a witness or to otherwise perform work related to any legal matter, the party responsible for my participation agrees to reimburse me at the rate of $350 per hour for time spent traveling, speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, and any other case-related costs.