Cornerstone Counselling - Child and Youth Therapy Consent Form

Who is Completing This Form?
I am completing this form as*

Parent or Legal GuardianCAS Worker or Agency Representative
Your Organization Name*
Example: Peel Children's Aid Society
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Phone Number
Please enter a valid phone number.
Department or Unit
Example: Child Protection Services

Understanding Therapy
Risks and Benefits

Counselling can lead to better relationships and reduced distress. However, therapy may involve discussing difficult topics. Your child may experience uncomfortable feelings such as sadness, anger, or frustration. We will work with you to manage these challenges effectively.
Parent Acknowledgment*

I understand the potential risks and benefits of therapy for my child
Confidentiality & Privacy
What We Share With Parents

To build trust with your child, we balance their right to privacy with your right to information. We will:
• Provide general themes and recommendations
• Involve you in consultation and occasional participation
• Share important safety concerns immediately

Limits to Confidentiality

We must break confidentiality if there is:
• Risk of harm to self or others
• Suspected child abuse or neglect
• Court order requiring disclosure
Parent Acknowledgment*

I understand the confidentiality policy and its limits

Custody & Consent Requirements
You must disclose if you are separated, divorced, or if the child is under Children's Aid Society (CAS) care or supervision.

If you are separated or divorced, you will need to provide legal proof of custody arrangements.
Are you separated or divorced from the child's other parent/guardian?*

YesNo
Who has the legal right to make healthcare decisions for the child?*

Sole (Only me)Joint/Shared (Both parents/guardians)Peel CAS / Other Children's Aid SocietyOther legal guardian
Because you are separated or divorced, we need proof that you have sole decision-making responsibility for your child's healthcare.

What to upload:
✓ Court order showing sole custody/decision-making
✓ Separation agreement confirming sole healthcare decisions

Important: Your child's therapy cannot begin until this documentation is verified.
Because you are separated/divorced and share custody, you need:
✓ Consent from BOTH parents (signatures required)
✓ A copy of your custody order or separation agreement

Your child's therapy cannot begin until both signatures and documentation are received.
Because a Children's Aid Society or legal guardian has custody, you need:
✓ Signature from the authorized CAS worker or legal guardian
✓ A copy of CAS placement documents or guardianship papers

Your child's therapy cannot begin until the legal authority signs and documentation is verified.
Upload Required Legal Documents*

Cancelof

Ending Counselling
You or your child may end counselling at any time, without penalty. While we prefer a closing session to properly end the therapeutic relationship, this is not required.
Acknowledgment*

I understand that services can be ended at any time

Child Information
Child's Full Legal Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Name of Therapist (If Known)
This consent is valid until:*

MonthDayYear
We recommend 12 months from today, or until you revoke consent in writing

Final Confirmation
By submitting this form, I confirm that:
✓ I have the legal authority to provide consent for this child's treatment
✓ All information provided is accurate and complete
✓ I understand the policies outlined in this document
✓ My electronic signature has the same legal effect as a handwritten signature
Should be Empty:

Child & Youth Therapy Consent Form