Welcome to Radical Elevation (RE). This document contains important information about our services, your child’s rights, and our clinic policies. Please read it carefully and note any questions you have so we can discuss them at your next appointment. When you sign this document, it will serve as an agreement between you, your child, and Radical Elevation.
Consent for treatment
I give my consent for my minor child to be assessed and treated by staff at Radical Elevation. Services may include individual therapy, family therapy, group support, and psychosocial skills training. I confirm that I have legal custody and the authority to provide consent for these services. Participation is voluntary and can be withdrawn at any time.
Parent and guardian communication with RE therapists
During your child’s treatment, the RE therapist may meet with parents or guardians either separately or together. Please remember that the client is your child, not the parent, guardian, or siblings. Any meetings with family members will be noted in the child’s clinical record, which is accessible to anyone or any entity with legal rights to it.
Consent for separated/divorced parents
If parents are separated or divorced, both legal guardians must provide consent for treatment unless a court order grants sole decision-making authority. In such cases, documentation of custody arrangements and contact information for the other parent must be provided.
Insurance and billing
If your child is covered by Medicaid, sessions will be billed through insurance. Please note that most insurance providers require RE to provide a clinical diagnosis, and sometimes additional information (like treatment plans or summaries). Once shared, this information becomes part of the insurer’s files, and while RE follows HIPAA guidelines, we cannot control how insurance companies handle the data once they receive it.
Cancellations, late cancellations, and no-shows
We understand that unexpected things happen, and you may occasionally need to cancel an appointment. Cancellations made more than 24 hours in advance are generally accepted without penalty. However, repeated cancellations, even with notice, may still affect your ability to maintain a consistent schedule.
Please refer to the Cancellations, Late Cancellations, and No-Shows Policy Consent Form for specific guidelines on fees, scheduling changes, and how repeated disruptions may impact your appointment availability.
Mandatory disclosures of treatment information
RE is sometimes required by law to disclose treatment information without child or parent/guardian permission.
Confidentiality cannot be maintained if:
- A child expresses plans to seriously harm themselves or others, and the therapist believes they can carry it out soon.
- A child engages in behavior that could cause serious harm to themselves or others.
- There is evidence or disclosure of past or present neglect or abuse (physical, sexual, or emotional).
- A court orders the RE therapist to provide information.
Disclosure of minor’s treatment information to parents
Therapy works best when there is trust between the therapist and the child. We aim to provide parents or guardians with general treatment updates but will not disclose private details shared by the child unless the child agrees, unless there is an immediate risk.
If something arises that the therapist believes parents should know, they will help the child find the best way to share this. In parent meetings, therapists may share general patterns or guidance to help you support your child without disclosing specifics.
Agreement not to use records in custody disputes
Our role is to support your child’s mental health, not to evaluate parenting or custody arrangements. By signing, you agree not to subpoena RE records or request court testimony for custody or visitation disputes. If a court legally compels us to testify, we will comply, but cannot provide recommendations related to custody or visitation.
Community resources and referrals
By signing below, you confirm that you have read and understood this document and agree to its terms for your child’s care with Radical Elevation.
Agreement
Your signature below indicates that you have read this document, understand its contents, and agree to its terms as part of your child’s care with Radical Elevation.