Family Counselling Consent & Agreement (Including Individual Sessions with Children)

Section 1: Parent/Guardian Informed Consent

I, the undersigned parent(s)/legal guardian(s), hereby give permission for our family, including the minor child(ren) listed below, to participate in family counselling with: Annie Baxter MPCC-Provisional at Mount Willow 

license Number 4578

supervisor: Debra Coffey 

Names of Minor Children Participating:

Nature and Purpose of Therapy: Family counselling provides support in navigating relationship challenges, communication, parenting, and emotional wellbeing. Individual sessions with children may be recommended as part of the process to support emotional safety and personal insight.

Section 2: Consent for Individual Sessions with Minor Children

I understand that my child may be seen individually as part of the family counselling process.

I give my informed consent for the counsellor to conduct individual sessions with my child(ren)

I understand that while individual sessions are confidential, information may be shared with parents/guardians only as appropriate and in the child's best interests, or when legally or ethically required.

I consent to participate in online counselling sessions via a secure video platform Psychology Today. I understand that while every effort will be made to ensure confidentiality and privacy, there are risks with technology such as disconnection or unauthorized access. I agree to be in a private space and will provide my current location, an emergency contact, and a phone number where I can be reached if the session is interrupted. I understand that in the case of an emergency or serious risk, the counsellor may need to contact emergency services.

Custody and Legal Authorization

Please confirm custody arrangement and who has the legal right to consent to treatment:

Parents are married/living together Parents are divorced/separated - joint legal custody One parent has sole legal custody Other (please specify):

If parents are separated/divorced, please provide custody documentation or parenting plan, if applicable.

Confidentiality & Information Sharing

Information shared in counselling is kept private and confidential, except where there is: Risk of harm to self or others Disclosure of abuse or neglect

By signing below, I confirm that:

I have read and understood the information above.

I have had the opportunity to ask questions. I voluntarily consent to participate in family and/or individual counselling for the listed children.

I consent to all participants under the age of consent to sign an understanding and agreement, or verbally consent to counselling (In a child friendly way) and that they fully understand and have the opportunity to ask questions.

Emergency Contacts – Innisfail & Central Alberta

Immediate Emergency
Call 911 for any life-threatening situation (police, fire, ambulance).

Mental Health Crisis & Suicide Support

9-8-8 Canada Suicide Crisis Helpline – Call or text 9-8-8 (24/7)
Alberta Mental Health Helpline – 1-877-303-2642 (24/7)
Addictions Support

Alberta Addiction Helpline – 1-866-332-2322 (24/7)
General Health Advice

Health Link Alberta – Call 8-1-1 to speak to a registered nurse (24/7)
Youth Support

Kids Help Phone – 1-800-668-6868 or text 686868 (24/7, free and confidential)
Community Resources & Referrals

2-1-1 Alberta – Dial 2-1-1 for information on local programs and supports (24/7)
Local Mental Health Office – CMHA Central Alberta (Red Deer)

Phone: 403-342-2266 (Monday to Friday, 9:00 am – 4:30 pm)
For evening/weekend support, use the Mental Health or Addiction Helplines listed above.