Wavelength Adolescent Privacy & Informed Consent Form

ADOLESCENT PRIVACY AND CONSENT FORM

Revised 2023 January
This document contains important information about your privacy, also called confidentiality, our professional services and business policies. Please read the entire agreement carefully, fill in the requested information, and make note of any questions you might have so that we can discuss them when we meet. Both you and your parent(s) or guardian(s) must e-sign the agreement and submit.
WHAT TO EXPECT: The purpose of meeting with a therapist is to get help with problems in your life that are bothering you. When we meet, we will ask questions, listen to you, and suggest a plan for working together. It is important that you feel comfortable talking to us about the issues that are bothering you. Sometimes these issues will include things you don’t want your parents or guardians to know about.

CLIENT INFORMATION:
Adolescent/Minor's Full Name
Last, First
Adolescent/Minor's Contact Number
Adolescent/Minor's Email
Preferred Method of Contact

PhoneTextEmailOther
PRIVACY: As a rule, we will keep the information you share with us sessions confidential, unless we have your written permission to reveal certain information. There are, however, important exceptions to this rule that are important for you to understand before you share personal information with your therapist in a session.

WHEN WE CANNOT MAINTAIN PRIVACY: In some situations, your therapist is required by law or by the guidelines of our profession to disclose information without either your consent or authorization:
- You tell me that you plan to cause serious harm to yourself
- You tell me that you plan to cause serious harm or death to someone else
- You tell me that you or another young person is currently being physically, sexually and/or emotionally harmed
- You tell me that you or another young person has been physically, sexually and/or emotionally harmed in the past
You can always ask your therapist questions about the different types of information we would share.

COMMUNICATING WITH YOUR PARENT(S) OR GUARDIAN(S): Except for the situations mentioned above, your therapist will not share with your parent and/or guardian things you share with them in your private therapy sessions.

This includes activities and behavior they would not approve of –or would be upset by – but that do not put you at risk or serious and immediate harm. However, if I feel that you are in such danger, I will communicate this information to your parent or guardian.
- Example: If you tell me that you have tried alcohol at a few parties, I will keep this information confidential.
- Example: If you tell me that you are drinking and driving, I will not keep this information confidential.
- Example: If you tell me that you are engaging in sexual activity, I will keep this information confidential.
Even if I have agreed to keep information confidential – to not tell your parent or guardian – I may believe that it is important for them to know what is going on in your life. In these situations, I will encourage you to tell your parent/guardian and will help you find the best way to communicate with them.You should also know that, by law in both the states of New York and New Jersey your parent/guardian has the right to see any written records we keep about our sessions. It is extremely rare that a parent/guardian would ever request to look at these records.
Wavelength Psychotherapy, LLC

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ADOLESCENT PRIVACY AND INFORMED CONSENT FORM

Parental Agreement to Respect of Adolescent/Minor's Privacy
Parent(s)/Guardian(s) Only: By checking the boxes and signing below you agree to respect your adolescent/minor's privacy while receiving mental health services with Wavelength Psychotherapy, LLC:

I will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed.Although I know that in this state, I have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these records in order to respect the confidentiality of my adolescent’s treatment.I understand that I will be informed immediately about situations that could endanger my adolescent/minor. I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment and may sometimes be made in confidential consultation.
Parent/Guardian(s) Full Name

First NameLast Name
Parent/Guardian(s) Full Name

First NameLast Name
Parent/Guardian(s) Signature

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Parent/Guardian(s) Signature

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Adolescent/Minor Client:

By agreeing and signing below indicates that you have reviewed the policies described above and understand the limits to confidentiality and your right to privacy while receiving mental health services with Wavelength Psychotherapy, LLC.
Adolescent/Minor Full Name

First NameLast Name
Adolescent/Minor Signature

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Date

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Date
Wavelength Psychotherapy, LLC

hello@wavelengthpsychotherapy.com
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ADOLESCENT PRIVACY AND CONSENT FORM

Wavelength Psychotherapy, LLC

ADOLESCENT PRIVACY AND INFORMED CONSENT FORM

Wavelength Psychotherapy, LLC