This document is to be considered as an addendum to the Informed Consent for Psychological Services. If you previously signed that document and would like a copy for your review, please let us know. 

 

Confidentiality

It is important for minors to have a “zone of privacy” in therapy where they feel comfortable discussing personal matters without fear that their thoughts and feelings will be immediately communicated to their parents. Children and teens often do not tell their parents everything, even when they have a very good relationship with their parents. Therapy is a safe place to discuss those private concerns.

Although the minor’s parents generally have a right to access the treatment records of their minor child, parents are urged to refrain, as this may irreparably harm the clinician’s relationship with the minor and preclude any further treatment gains from being made.

The clinician will inform the parents of information the minor has disclosed that would place the minor or someone else at risk of serious harm. Examples may include, but are not limited to, regular drug or alcohol use, any use of serious drugs such as heroin and opiates, dangerous sexual activity, and involvement in serious criminal activity.

Examples of information the clinician will generally not disclose to the parents without the minor’s assent include, but are not limited to, sexual orientation, having tried alcohol or marijuana a few times, or having had voluntary, protected sexual activity with a similar-age peer. That said, the clinician will offer information and guidance to the minor child regarding the risks of their behavior and will monitor the behavior.

The clinician is required by law to disclose information to individuals other than the minor’s parents in cases of abuse disclosure, imminent risk of self-harm or harm to others, and court orders.

 

Telehealth

This section applies if your child will be receiving any services by telehealth.

With the addition of technology, some additional challenges arise. In an office setting, if a minor discloses imminent risk to self or others, we are in a controlled environment where we can more easily take action to keep our clients from harm. Oftentimes, the parent of the client will be present in the waiting room or session, and if not, we can attempt to keep them minor child in a safe environment until a parent arrives.

If your child is receiving mental health care via telehealth, we may be unable to confirm the location of the minor child or whether their parent or legal guardian is nearby. In the event that we believe the minor client is at imminent risk of harm to themselves or someone else during a telehealth session, we will take the following steps:

• We will attempt to identify the location of the minor client. While we do have home addresses on file, we may not know where the minor is located during the time services are rendered.

• We will attempt to keep the minor client online while we make efforts to reach the legal guardian via phone.

• If we are unable to reach a parent or legal guardian, we will leave a message detailing what was disclosed, and we will contact the local police department for a wellness check.

If information is disclosed during a telehealth session that falls under the category of risky behavior but is not considered imminent risk of harm to the client or others, we will attempt to contact you by phone. 

Authorization for mental health treatment of a minor when parents are not married

The adult who signs the Psychological Services Agreement attests that they have the legal authority to independently consent to medical services for the minor child being seen.

Please provide our office with the most recent custody decree that demonstrates that you have the right to authorize treatment for the child.

It is our policy to notify the child’s other parent that the child is being seen here unless there are exceptional circumstances.

If parents disagree about the child’s treatment, the clinician will attempt to resolve it by listening to both parents and explaining their perspective and recommendations regarding the child. If either parent decides that therapy should not continue, we must honor that decision unless there are extraordinary circumstances. We will request the option of having a few closing sessions with the child to end the treatment relationship in an ethical and appropriate manner.

If, during treatment, the minor’s parents become or are already involved in child custody litigation, please be aware that the clinician will be of limited use in such litigation. If the clinician is required to testify, they will testify only to the facts regarding the minor’s treatment and will not render any opinions regarding either parent’s fitness or child custody arrangements.

If the clinician is required to perform any work related to a legal matter, the party requesting participation agrees to pay $250.00 per hour, billed in 15-minute increments, for the clinician’s time spent traveling, speaking with attorneys, reviewing and preparing documents, attending meetings or court hearings, and any other costs associated with the legal matter. These fees are not healthcare services and cannot be billed to health insurance companies.

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