Minor Child Treatment Agreement for Lori Conroy, LMFT

Your Legal Name:*

Your email address:*

example@example.com

Your relationship to the Minor Child:*

MotherFatherLegal Guardian

Minor Child's Legal Name:*

As the above-listed mother, father or guardian ("Parent") of the above-listed minor child (“Child”), I consent for myself and for my child to participate in counseling with Lori Conroy, LMFT (“Therapist”).

Please note that the Therapist requires that both parents to complete this form prior to providing therapy to a minor child. If any question exists as to authority of a parent to give consent, Therapist will require supporting legal documentation.

I understand and agree that all information and communication in counseling shall be confidential. The only exceptions to this will be in situations where the Therapist is required by law to report child abuse or neglect, elder and dependant adult abuse, and threats of severe harm to oneself or others.

Therapy can only be effective if there is a trusting relationship between the Child and Therapist. Although parent or guardian can expect to be kept up to date as to the child’s progress, you will not be given detailed information. You can expect to be informed of any serious concerns the Therapist has regarding safety or well-being of your child.

The Therapist will not voluntarily participate in any litigation, or custody dispute, or write letters or reports to be used in a client’s legal matter. I agree that neither I nor anyone representing me shall call on the Therapist during counseling or at any time subsequent to it to provide either written or oral testimony at deposition or in court on any issue related to custody and dissolution of marriage, nor shall I subpoena any records for such purposes. Therefore I waive any right, which I may have to call the Therapist or subpoena such records in this or any dissolution action, which is or may be filed.

I further understand that I am expected to remain on-site during my child’s therapy. I understand that parents are expected to wait in the waiting room for children under the age of 12 for the duration of the session. This policy enables me to be available should I be needed in the counseling process. Under no circumstances should children under 12 be left in the waiting room alone.

I have read, understand and agree to comply with the above policies.

Your Signature*