I / We give Erin Bunnell, LMFT permission to contact me / us at the following numbers and email address:

 

I / we understand that online counseling services include, but are not limited to, consultation and treatment using interactive audio, video, and data communications. I /we  understand that tele-therapy services involve the communication of the minor's medical/mental health information to the above referenced provider. I / we have the right to withhold or withdraw consent at any time without affecting the minor's right to future care or treatment; nor risking the loss or withdrawal of any benefits to which the minor would otherwise be entitled.

I / we understand that the laws that protect the confidentiality of the minor's medical information also apply to online counseling services. As such, I / we understand that the information disclosed by the minor during the course of therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting abuse; expressed threats of violence towards an ascertainable victim; and where the minor's mental or emotional state an issue in a legal proceeding. I / we understand that the dissemination of any information is under the same HIPAA standards as traditional therapy.

Although rare, I / we understand that there are risks to Internet based services including, not limited to, the possibility, despite reasonable efforts on the part of the therapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of the minor's medical information could be accessed by unauthorized persons in the case of hacking or breach.

I / we agree that the location of the therapy is in California where Erin Bunnell is licensed. I agree that my therapy is under the licensing rules and laws of the state of California.

I / we am aware of potential benefits and risks of the minor participating in on-line therapy services. Some benefits may include improved access to services, being able to choose the therapist I / we want with specialty experience, and the convenient access to therapy and the therapist of our choice.  

Although rare, I / we am aware of possible risks of tele-therapy which include that the information given may not be sufficient to allow for a diagnosis, that there may be delay in response from the therapist due to technical failures or unforeseen events, and that the minor may not be able to respond to my therapist due to technology failures or unforeseen events.

I / we understand that the therapist may not be able to provide certain services to the minor. via tele-therapy.  If the therapist believes that the minior might need additional or other services, they may refer to another specialist or type of care, such as seeing a medical doctor for further evaluation and treatment.

It is not recommended that the minor suddenly stop contacting the therapist or "drop out" without talking about the termination of therapy. Therapists and clients talk about the expected length of therapy and ending the therapeutic relationship.

Informed consent continues throughout the course of therapy and the therapist will continue to talk with me about risks, benefits or educate the minor on the process of therapy on an ongoing basis.

 

 

1) If the minor child has NOT been the subject of a custody dispute/agreement the consent of either parent is legally sufficient to initiate treatment.

2) If a custody order has been issued, we must receive a copy of the custody order to verify which consent(s) is/are legally required to authorize treatment. In the case of a court order for joint legal custody, the default position is that either parent may consent to treatment unless the custody order states otherwise.

3) Under some circumstances a minor over the age of 12 years may be able to consent to his/her own treatment. This may be the case if the minor is the victim of incest or other abuse or if the minor would present a danger of serious physical or mental harm to self or others without the mental health treatment. If a minor is to consent to his/her own treatment, s/he must be mature enough to understand the informed consent and to intelligently participate in therapy. Even if the minor is able to consent to his/her own treatment, the treatment should involve the parent(s) unless, in the opinion of the therapist, parental involvement would be inappropriate.

4) Ethical standards typically require the involvement of both parents when treating a minor. Some exceptions to that ethical guideline may exist if the therapist reasonably believes that the involvement of one of the parents could significantly harm the child or the therapy relationship.

5) A minor has the right to confidentiality in his/her relationship with a therapist. Typically, the therapist will not disclose information provided by a minor client to the minor’s parents unless there is a compelling reason to do so. Examples of compelling reasons might include activities or situations that pose a substantial risk of harm to the minor client such as heavy drug use or involvement in significant criminal activity.

6) In therapy the identified client is the one who has the right to a confidential relationship with the therapist. In the case of a minor client, this means that the parents do not have confidentiality with the therapist unless the parents are also identified as clients.

7) Parents may request access to their child’s records. The therapist may agree to allow the parents access to the record or may provide a summary. In some cases the therapist may deny parental access to the child’s record. This is legally and ethically appropriate if the therapist believes that allowing the parent access could harm the child or the therapy process.

8) The signature of one parent is typically sufficient to allow release of a minor’s record to another provider unless there is a court order requiring that both parents’ signatures be obtained to release a minor’s record.

9) In is common that parents might participate in their child’s therapy and give input from time to time, however, they are merely visitors in their child’s therapy when they do so.

 

CONSENT:       I have read this Informed Consent for Treatment/Evaluation of Minors.  I/We have been provided with an opportunity to ask any questions needed for clarification, received answers to all such questions, and with my/our signature(s) affirm that I/we understand it and agree to treatment without any implied guarantee as to therapy results or outcome.

                 I/We authorize and request that Erin Bunnell, M.A., LMFT to carry out psychotherapeutic evaluations, treatments, and/or diagnostic procedures which now or during the course of the minor’s care as a client are advisable.  I/We understand that the purpose of such procedures will be explained to me/us and will be subject to my/our agreement.

I / we understand that when I / we participate in my child's therapy that it is strictly as a visitor or consultant and that I do so solely for the furtherance of their therapy process.   I / we understand that I am not a client of Erin Bunnell and that my disclosures during meetings are not confidential and are not protected by the psychotherapist-patient privilege.