Confidentiality Statement for minors
In an effort to create and maintain the most productive therapeutic experience for your child, please consider two concerns. First, it is important for your child to feel comfortable in knowing that the content of their therapy sessions will remain confidential unless there is an imminent danger to that child or another person. Second, in order to allow your child to feel that all concerns can be safely discussed, it is necessary for your child’s therapist to remain neutral and uninvolved in any parental custody determinations. Please note that Cognizant Behavioral Health Services does not provide custody evaluation services. If you wish to obtain a custody evaluation, you may ask your therapist for a referral. Your signature below indicates your agreement with treatment conditions explained above.
I agree that I will not seek treatment records nor request Cognizant Behavioral Health services’ participation in any custody determination proceedings regarding my child. I understand that CBHS will not be responsible to notify the other parent in case one parent requests a copy of your child’s PHI for any other purpose.
In case of divorced parents, a copy of custody agreement is needed on file before the child is evaluated by the clinician. It is parents’ responsibility to inform CBHS regarding any new updates child custody arrangements.