Behavioral Health Adolescent Informed Consent for Assessment and Treatment

Adolescent Informed Consent for Assessment and Treatment
Child/Adolescent Behavioral Health Client:

Signing below indicates that you have reviewed the policies described and about and understand the limits to confidentially. If you have any questions as we progress with therapy, you can ask, your therapist at any time.
Minor's Signature *

Clear
Date *

Month Day Year
Date
Parent/Guardian:

Check boxes and sign below indicating your agreement to respect your adolescent’s privacy:
Yes I understand that I will be informed about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment and may sometimes be made in confidential consultation with the
Yes*
Although I know I have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these records in order to respect the confidentiality of my adolescent’s treatment.ea
Yes* I will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I will be provided with periodic updates abut general progress, and/or may be asked to participate in therapy session as needed.
Parent Guardian Signature: *

Clear
5000 Blackmore Rd., Casper WY 82609

(307)233-6000

www.chccw.org
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Adolescent Informed Consent for Assessment and Treatment