Consent for Treatment of a Child

NOTE: This form needs to be individually completed.

Risks and Benefits

Counseling for children can have benefits and risks. Since therapy often involves discussing unpleasant aspects of one’s life, your child may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness and helplessness. Working through difficult emotions can sometimes lead to an increase in difficult behaviors before the child is able to utilize new skills or fully integrate their experiences. On the other hand, counseling has been shown to have benefits for individuals who go through it. Therapy can lead to better relationships, solutions to specific problems, significant reductions in feelings of distress and improved self-esteem. But there are no guarantees of how a child will respond. Children are unique and holistic beings that sometimes require assistance and support in order to grow and develop to their fullest potential. Counseling can often be beneficial for children and their families and one way of working with children is to utilize play in a therapeutic manner. Play can be explained as the language of children. The use of therapeutic play enables a child to re-organize or make sense of their world; it can also serve to strengthen a child’s sense of self and to gain mastery over their world or their “problems.” Using play to explore a child’s experience gives the child psychological distance and provides an opportunity to express themselves or themself in a safe way. In providing counseling to children, and in using play as a therapy technique, I invite the child into a special “playtime” but I am not a “play partner.” Rather my role is more significant as I read, follow, interpret, and respond to the child’s play.

Confidentiality

All records and communications about and the services provided are kept secure and confidential except within the situations listed:

• serious immediate threat to your child's life or welfare
• serious immediate threat to the life or welfare of another person
• actual or suspected child neglect
• report of imminent danger to the community at large
• court subpoenas
• investigation by Child and Family Services Authority

Your child's therapist may consult with other professional therapists, educators, and supervisors in order to provide you with the best treatment possible. By signing this form you understand that information about treatment and care may be shared with other professionals for quality assurance, consultation and supervision purposes.

Revoking Consent

Both you and your child may end the counseling relationship at any time, without penalty or prejudice (with the exception of late cancellations/no shows). While free to discontinue services at any time, it is preferable to have a closing session or phone call, to ensure the child understands that counseling is ending and to provide an appropriate closure to the experience. You may also have the right to refuse or discuss modifications of any of my counseling techniques or suggestions that you believe may be harmful.

Acknowledgment and Consent:

By your signature below, you are indicating that you read and understood this consent form or that any questions you had about this consent form were answered to your satisfaction.

Consent for Treatment of Minors:

I/we consent that my child under the age of 16,

Child Name:*

First NameLast Name

Child Date Of Birth:*

Date

may be treated as a client by Luciak & Associates Ltd. This form is in effect for 12 months after the consent is completed/provided.

Consent can be revoked in writing at any time.

Parents:

Please do not leave the office while your child is with their therapist unless discussed with your therapist. Your presence may be necessary during your child's visit.

To be treated/seen by Therapist: *

Parent or Guardian’s name:*

First NameLast Name

Parent or Guardian's Signature:*

Date:*

Date

If there are any child custody agreements in place, please provide the most current version to us:

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Are both of the parents/guardian's in agreement with counselling treatment provided by Luciak & Associates Therapy Clinic?*

YesNoOther

If shared custody is in place, please provide the full name and phone number for the other parent/guardian:*

If you are the sole legal guardian, enter "Sole Legal Guardian/Parent"

Does your child already have an appointment booked with us?*

Yes, an appointment is scheduledNot yetUnsure if an appointment is scheduled at this time

Client Contact Info

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance

Direct Billing may be available for some insurance providers. Does your child have an insurance plan?*

Yes (I am wanting direct billing and will provide the information below)Yes (but I will pay upfront and submit myself)No (I will pay debit/credit)

Health Insurance Provider:

Please select if you are wanting direct billing.

(Optional) If you are unsure of the policy numbers, you can upload a picture of the insurance card here:

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If yes, please specify the name of the provider:

If yes, please specify the Plan or Member I.D. #

If yes, please specify the Group Number #

Upon completion of this intake form you will be redirected to a form to provide credit card information.

This is necessary in the event of appointments cancelled with less than 24 hours notice.