INFORMED CONSENT FOR TREATMENT OF A MINOR (F)

INFORMED CONSENT FOR TREATMENT OF A MINOR
FaithWorks Therapy, LLC Shanae Farquharson, MS, MFT
This agreement applies to psychotherapy services provided to a minor child and outlines the rights and responsibilities of the parent(s)/legal guardian(s), the minor client, and the therapist.
IDENTIFYING INFORMATION
Minor Client Full Legal Name:*
Date of Birth:*

MonthDayYear
Date
Parent/Legal Guardian Full Name:*
Relationship to Minor:*
Phone Number:*
Email Address:*
example@example.com
PARENTAL AUTHORITY & CONSENT
I affirm that I am the legal parent or court-appointed legal guardian of the above-named minor and that I have the legal authority to consent to mental health treatment on their behalf.
I understand that if there are multiple legal guardians, consent from all parties may be required unless otherwise specified by court order.
I confirm I have legal authority to consent to treatment
NATURE OF THERAPY WITH MINORS
Therapy with minors may include individual sessions with the child, sessions with the parent(s)/guardian(s), or family sessions, depending on clinical needs.
The primary client is the minor child, even though the parent or guardian has consented to treatment and may be financially responsible.
I understand that the minor is the primary client

CONFIDENTIALITY & PARENT ACCESS
Information shared by a minor in therapy is treated as confidential to support a safe and effective therapeutic relationship.
As a general policy: Parents/guardians will receive general information about treatment progress. Specific session content will not be disclosed without the minor's consent
Confidentiality may be breached if. The minor is at risk of harm to self or others. Abuse or neglect is suspected or disclosed Disclosure is required by law or court order
I understand the confidentiality limits in minor therapy
COMMUNICATION WITH PARENTS/GUARDIANS
Parent sessions may be scheduled as clinically appropriate. These sessions are considered part of the minor's treatment.
Email, messaging, or phone communication is limited to scheduling, billing, or general updates and is not considered therapy.
I understand communication boundaries
TELEHEALTH CONSENT FOR MINORS
I consent to my child receiving therapy services via secure telehealth platforms.
I understand: A parent/guardian must ensure privacy and safety at the child's location. Telehealth is not appropriate for emergencies. I must provide the child's accurate physical location for each session
I consent to telehealth services for my child
FEES, PAYMENT & CANCELLATION
The parent or legal guardian is financially responsible for all fees.
Payment is due prior to session start
Cancellation Policy: 24+ hours notice: Full refund Less than 24 hours: Non-refundable. Missed sessions: No refund
I agree to the payment and cancellation policy

PARENTAL CONDUCT & EXPECTATIONS
I agree to:
- Support the therapeutic process
- Refrain from pressuring the therapist for confidential disclosures
- Respect professional boundaries
- Notify the therapist of any custody or legal changes
I agree to these expectations
COURT INVOLVEMENT & LEGAL MATTERS
Therapy is not forensic in nature. The therapist does not provide custody evaluations, court recommendations, or testimony unless required by law or subpoena. Any court-related involvement may incur additional fees.
I understand the limits regarding legal matters
ELECTRONIC SIGNATURE & AGREEMENT
By signing below, I confirm that I have read, understand, and agree to the terms of this Minor Consent and Parent Agreement.
Parent/Legal Guardian Electronic Signature:*

Clear
Date:*

MonthDayYear
Date
If applicable:
Second Parent/Legal Guardian Name:
Electronic Signature:

Clear
Date:

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES (HIPAA) – MINOR CLIENTS
This Notice describes how Protected Health Information (PHI) related to a minor client may be used
and disclosed, and explains the privacy rights of both the minor client and the parent or legal guardian.

Please review it carefully.

Who Is the Client?
In therapy services provided to a minor, the child is considered the primary client. Parents or legal
guardians may have rights to access records; however, confidentiality is maintained to the extent
permitted by law and professional ethics.

Our Responsibilities
We are required by law to maintain the privacy and security of PHI, provide this Notice, and notify
affected parties if a breach of unsecured PHI occurs.

How We May Use or Disclose a Minor’s PHI
• Treatment: To provide and coordinate mental health care for the minor.
• Payment: To obtain payment for services provided.
• Health Care Operations: For supervision, consultation, quality assurance, and administrative
purposes.
• As Required by Law: Including reporting abuse or neglect, responding to court orders, or preventing
serious harm.

Parent / Guardian Access to Records
Parents or legal guardians may receive general information regarding treatment progress. Access to
detailed session content may be limited to protect the therapeutic relationship unless disclosure is
required by law or necessary to prevent harm.

Psychotherapy Notes
Psychotherapy notes are kept separate from the clinical record and are not disclosed without written
authorization, except as required by law.

Minor Privacy Rights
To the extent allowed by law, minor clients have privacy rights in therapy. These rights may limit
parental access when disclosure could reasonably be expected to cause harm.

Your Rights
You have the right to:
*/-• Request access to or copies of health records (subject to legal limits)
• Request amendments to records
• Request confidential communications
• Request an accounting of disclosures
• Receive a paper or electronic copy of this Notice

Changes to This Notice
We reserve the right to change this Notice and make the new provisions effective for all PHI we maintain.

Complaints
If you believe privacy rights have been violated, you may file a complaint without retaliation by
contacting:
Shanae Farquharson, MS, MFT
FaithWorks Therapy, LLC
Email: sfarquharson@faithworkstherapy.com
I acknowledge receipt of the Notice of Privacy Practices and understand how my child's Protected Health Information (PHI) may be used and disclosed.
I acknowledge the HIPAA Notice

INTAKE QUESTIONNAIRE

Youth Self-Report (Ages 10–17): The following questions are designed to be answered by the child or teen. There are no right or wrong answers. A parent or guardian may help with reading or understanding the questions, but answers should come from the youth whenever possible.
What made you decide to come to therapy right now?*
You can share as much or as little as you want.
What are you hoping therapy will help you with?*
(For example: feeling less stressed, handling emotions, improving relationships, feeling more like yourself.)
Have you ever talked with a therapist or counselor before? Yes or No? If yes, Was there anything that felt helpful or unhelpful about that experience?*
Has a doctor, therapist, or other helper ever told you that you have something like anxiety, ADHD, depression, or another mental health condition?*

NoYesI'm not sure.
If yes, Do you remember what they called it?
Do you take any medications to help with your mood, feelings, focus, or behavior? Yes or No? If yes, Do you know the name of the medication(s)?*
Have you had any thoughts about hurting yourself or someone else?*

NoYes, in the past.Yes, recently.I'm not sure.
If yes or not sure, would you like to talk more about this with your therapist?*

NoYes
Should be Empty:

INFORMED CONSENT FOR TREATMENT OF A MINOR

IDENTIFYING INFORMATION

PARENTAL AUTHORITY & CONSENT

NATURE OF THERAPY WITH MINORS

CONFIDENTIALITY & PARENT ACCESS

COMMUNICATION WITH PARENTS/GUARDIANS

TELEHEALTH CONSENT FOR MINORS

FEES, PAYMENT & CANCELLATION

PARENTAL CONDUCT & EXPECTATIONS

COURT INVOLVEMENT & LEGAL MATTERS

ELECTRONIC SIGNATURE & AGREEMENT

NOTICE OF PRIVACY PRACTICES (HIPAA) – MINOR CLIENTS

INTAKE QUESTIONNAIRE