• CONSENT FOR COUNSELING SERVICES TO CHILD(REN)

  • Clients Who Are Dependents:
                    If you are requesting services for a child(ren) as the guardian, the parent, or Managing Conservator/ Possessor Conservator of that child, it will be critical that the child trust the therapist. With your understanding in advance, we shall keep what your child says/does confidential.
                    If we think it would be helpful to share a specific detail with you, we shall first ask the child's permission to do so, or we shall encourage the child to do so. It is important to the therapy process that he/she does not think the parent and the therapist are conspiring against him/her in any way. You have the right and responsibility to question the therapy process, to understand the nature of activities with the child, and to be informed of the child's progress. We have the right to use our clinical discretion as to what is appropriate disclosure. We shall review the child's progress in therapy with you, and we want to obtain feedback from you regarding your interactions with the child and observations of the child in various settings. In this way, we shall work as a team. We shall value your consultations with us and your involvement. We shall discuss with you how you can participate effectively in the child's treatment and progress outside of therapy.

    Client Rights:
                  Clients are also assured of confidentiality, which is a protected ethical right and a California state law, subject to legal limits. Cases may be discussed with other therapists within this agency in order to provide continuing care and/or treatment options. Should we believe it beneficial to us and to you to consult with another professional outside our agency regarding your case, we shall notify you and obtain a release of information signed by you. At times, we may seek professional supervision or consultation of the case without identification of the client in any way. There are some exceptions to confidentiality, which are addressed below.

    Duty To Warn - Confidentiality
        The following are exceptions to confidentiality:

    • We are required by law to report any incidence of suspected child abuse, neglect, or molestation in order to protect the child involved;
    • In legal cases, we or our records may be subpoenaed by the court system;
    • Whenever obligated by law or a judge to share confidential information;
    • Whenever there is a legal exception to confidentiality;
    • You authorize us to notify relevant other (including a possible victim) and/or law enforcement authorities, if we judge that a client has an intention to harm self or others.

  • Other Exceptions to Confidentiality are as follows:

    • Managed care organizations usually require that we consult with their case managers and
      provide progress updates to their organization. This is how their personnel determines whether to provide you with necessary authorization for visits. If you have a managed care plan, we have no control over the data required by your organization once it leaves our office.
    • Insurance verification
    • In divorce cases in which parents share joint custody, either parent has a right to the
      child's record, unless otherwise stipulated in the divorce decrees.

    Keep this first page for your records.

     

     SIGNATURE STATEMENT

  • 1. The minor(s) named below live in my home and I am 18 years of age or older.
        
    2. Name of Child: Child's Date of Birth: Pick a Date   
    2. Name of Child:  Child's Date of Birth: Pick a Date   
    3. Your Name(please type):      

    4. Your relationship to child(ren):     

             

    5. I hereby swear that I have the following legal custody (circle appropriate):

            

    6. I hereby swear that I have a legal right to obtain treatment for the above-named

    child(ren):       

    7. In instances of divorce, it is essential that the legal custodian of the child(ren) grant

    permission for the services. If you are a divorced parent, a stepparent, a grandparent, a

    guardian, or other, you may be asked to provide a copy of the court order which names

    you the legal custodian of the above child(ren). Are you willing to do so?  

             

  • If the answer to any of the above questions is “No,” counseling services can not be provided to the above-named child(ren) until a copy of the court order which names you the legal custodian is provided to this office.

    • I have read, understand, and agree to the Confidentiality Statement and the Informed Consent/Duty to Warn (exceptions to confidentiality) for TRUTH, HEALING & EVOLUTION LLC
    • I am aware of its content and policies and understand that a copy of this Signature Statement will be a part of my case record.
    • I have read it and if necessary, I have discussed and clarified my understanding of it with a representative of the TRUTH, HEALING & EVOLUTION LLC.
    • I agree to abide by the terms/policies set forth in this document.
    • I consent to have the above named minor(s) receive therapeutic services provided through
    • TRUTH, HEALING, EVOLUTION LLC (T.H.E.) without a parent or guardian present.

  •    Pick a Date   

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