AGREEMENT FOR PARENTS & GUARDIANS
Psychotherapy can be an important resource for children. A therapeutic relationship can be beneficial
by:
• Facilitating an open and appropriate expression of the strong feelings which routinely accompany
emotional and mental difficulties, including guilt, grief, sadness and anger.
• Providing an emotionally neutral setting in which children can explore these feelings.
• Helping children understand and accept their emotional and mental health needs and how to
appropriately communicate these needs to the important people in their lives such as their parents,
siblings, family, friends, etc.
• Offering feedback and recommendations to a child’s caregivers based on knowledge of the child’s
specific emotional needs and developmental capacities.
Who can authorize treatment for Minor
In order to authorize mental health treatment for your child, you must have either sole or joint legal custody of
your child.
• If you are married, only one parent needs to consent for treatment for your child.
• If you have joint legal custody of your child – both parents must consent for treatment and a copy of the
divorce decree needs to be provided.
• If you are separated but still legally married, only one parent needs to consent for treatment, however,
please be aware that it is our policy to notify the other parent we are meeting with your child. We
believe it is important that all parents have the right to know, unless there are truly exceptional
circumstances, that their child is receiving mental health evaluation or treatment.
Confidentiality
In some situations, we are required by law or by the guidelines of our profession to disclose information,
whether we have you or your child’s permission. Confidentiality cannot be maintained when:
• Child patients tells us they plan to cause serious harm or death to themselves or others and we believe
they have the intent and ability to carry out this threat in the very near future. We must take steps to
inform a parent or guardian or others of what the child has told us and how serious we believe this threat
to be and to try to prevent the occurrence of such harm.
• Child patients 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, we will need to use my
professional judgment to decide whether a parent or guardian should be informed. • Child patients tell us, or we 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, we are required by law to report the alleged abuse to the appropriate state childprotective agency.
• We are ordered by a court to disclose information.
Divorce, Custody or other Legal Disputes
In the cases of separation and divorce, we ask parents to remember that this decision was not initiated or made
by the child, but he or she must find a way to deal with and come to terms with this change in their family. The
usefulness of such therapy is extremely limited when the therapy itself becomes simply another matter of
dispute between parents. With this in mind, and in order to best help your child, we strongly recommend that
each of the child’s caregivers mutually accept the following as requisites for the child’s participation in therapy.
• It is our primary responsibility to respond to your child’s emotional needs. This includes, but is not
limited to, contact with your child and each of his or her caregivers, and gathering information relevant
to understanding your child’s welfare and circumstances as perceived by important others (e.g.,
pediatrician, teachers, psychologists, social workers, etc.). In some cases, this may include a
recommendation that you consult with a physician, should matters of your child’s physical health be
relevant to this therapy.
• We ask that all caregivers remain in frequent communication regarding this child’s welfare and
emotional wellbeing. Open communication about his or her emotional state and behavior is critical. In
this regard, we invite each of you to initiate frequent and open exchange with their therapist.
• In the course of treatment, we may meet with the child’s parents/guardians either separately or together.
Please be aware, however, at all times, our patient will always be your child – not the parents/guardian, siblings or other family members of that child. We recommend that parties who are disputing custody strongly consider participation in alternative forms of negotiation and conflict resolution, including mediation and custody evaluation, rather than try to settle a custody dispute in court. We make it clear to the families we work with that we do not make custody evaluations or recommendations for court. There are two key reasons for this position. The first is that we see it as a conflict of interest. If the child or family we are engaged in therapy with knows we may be making a custody recommendation, they may come in with a hidden agenda that will interfere with the therapy's effectiveness. Secondly, we see custody evaluation as a specialized area that requires additional training past a standard mental health degree. We have chosen not to specialize in this area and therefore do not practice in this area. It is crucial for us to set and maintain firm boundaries on this issue because there is often still important work to be done post-divorce.
Your understanding of this may not prevent a judge from requiring our testimony, even though we will not do so unless legally compelled. If we are required to testify, we are ethically bound not to give our opinion about either parent’s custody, visitation suitability, or fitness. If the court appoints a custody evaluator, guardian ad
litem, or parenting coordinator, we will provide information as needed, if appropriate releases are signed or a court order is provided, but we will not make any recommendation about the final decision(s). Furthermore, if we are 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 their therapist at the rate of $ per hour for time spent traveling, speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, and any other case-related costs.
Appointments
Please make every effort to get your child to their appointment on time. We kindly ask for at least 24-hour cancellation notice by phone, directly to your therapist extension. If you cancel or no show after the 24-hour period, no matter what the reason is for cancellation, you will be charged a missed flat rate fee of $100.00, regardless of what you currently pay per session. The missed fee is your responsibility and cannot be billed to your insurance company.
We strive to provide a safe and peaceful environment for all our clients. As such, we ask that you not leave unattended minors at the clinic at any time. It is likely that your child’s therapist has sessions before and after your scheduled time and cannot be responsible for your child after the session has ended. We encourage you to stay at the office for the length of your child’s session but understand that unexpected situations may require that you briefly leave our location. Should these situations arise, we ask you to inform your therapist at the start of the session, so that they are aware of your absence. We also ask that you return 15 minutes prior to the end of your child’s therapy session. This ensures that your child’s therapist can update you (if needed) and schedule upcoming sessions. Additionally, we ask that you come into the building to pick up your child at the end of the appointment time.
Payment
Payment for my services is due, in full, at the time of service. Who pays for this service is not ours to decide.
If you are divorced and the court has issued both parents pay 50/50 for counseling, the two of you will have to settle that outside of our office. We will not split, divide or partial bill each parent.
Your understanding of these points and agreement in advance of starting this therapy may resolve difficulties that would otherwise arise and will help make this therapy successful. Your signature, below, signifies that you have read and accept these points.