Consent for Treatment; Minor
Name of Minor Child
Name of Parent giving consent
I understand that my minor child will be engaging in psychotherapy at In One Peace Counseling Services. My child’s therapist will be
Dr. Jessica Dorland MS MEd LPC DBH
Chris Heinisch MC LAC NCC
Karen Schill MC LPC
Danielle Breckenridge LPC
The purpose of this treatment is so that my child feels better or resolves specific life or adjustment problems that have caused me to seek assistance on behalf of my child. The primary procedure used by my child’s therapist is talk therapy. She utilizes a variety of techniques which are likely to include any of the following: dialogue, interpretation, cognitive reframing, awareness exercises, self-monitoring experiments, visualization, journaling, drawing, or reading assigned books. She may use play or games to draw my child out. She may recommend that my child also see a physician or non-traditional (homeopathic and Oriental medicine) practitioners. The potential benefit of treatment is that my child will feel better about his or her life, learn to manage stress, experience relief from painful emotions, or resolve problematic issues. I understand that a “cure” is not guaranteed and that it is possible that as my child talks about some things, he or she may even feel worse. He or she may experience emotions more intensely as he or she talks about things that are upsetting, or I may notice more conflict in relationships as my child make changes.
I understand that all information my child shares will be kept confidential, but that this confidentiality is not absolute. In the case of medical emergency, child/elder abuse or neglect, suicidal or homicidal intent, or under court order, clinical information may be released. I further understand that my therapist, my child, and I will discuss and agree upon the extent to which information my child provides to my therapist is shared with me.
I understand the therapist I will see, is:
an independently licensed professional counselor, social worker, or marriage and family therapist, and as such is not obligated to receive clinical supervision. However, in an effort to provide services that reflect best practices, my therapist may regularly meet in a peer consultation group in which cases are discussed and additionally may consult with an identified Clinical Consultant. I understand that if my case is discussed in the peer consultation group or with the Clinical Consultant I will not be identified by name. Should the Clinical Consultant review records containing Protected Health Information the Consultant will be bound by the same rules about confidentiality as is my therapist.
licensed at the associate level as a professional counselor or social worker and receives regular clinical supervision from a team of independently licensed clinicians. The clinical supervisor of that team is Dr. Jessica Dorland LPC who can be reached at (520) 302-4116.
I understand that I can have a copy of my child’s records provided to another person or to me by completing a Release of Information form and that a session fee may be charged for this service.
I understand that both my child and I have the right to participate in treatment decisions and that my child’s therapist and my child will together develop and periodically review and revise a treatment plan which will identify goals for treatment as well as the means of achieving those goals. I understand that I have the right to refuse any recommended treatment and that I may withdraw my consent to treatment at any time with no consequences.
I understand that the fee for a session is $150. If I my child’s treatment is paid for by my insurance company, I understand that I am responsible for any co-pay. In addition, should my insurance company not cover my child’s treatment, I understand that I am responsible for the full session fee. My child’s therapist will provide a receipt or statement upon request. I understand that my child’s therapist may negotiate a reduced fee for my child if treatment is otherwise not affordable. I understand that additional fees may occur in instances of preparation of letters or documents, home visits, phone calls lasting longer than 7 minutes, attendance to meetings, consultations, etc. I understand that a $30 fee will be assessed for any check returned for Non-Sufficient Funds. 24-hour notice is required in instances of cancellations or change in appointment. Late cancellations or No-Show will incur a fee of $50 although my child’s therapist may waive this fee at her discretion,
I have read the above information and consent for treatment.
I am married to my child's other parent and am consenting to my child's therapy for both of us.
My child's other parent is signing a second consent form and I understand that this is a requirement for continued treatment of my child.
My child’s therapist has been provided with a copy of a custody agreement documenting that I have the sole right to make medical decisions.
My child’s other parent is unknown, deceased, or otherwise unreachable and I accept full responsibility of providing consent for his/her/their care.
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