Agreement for Service & Informed Consent for Minors Form 2017-01-17T22:17:27+00:00

Agreement for Service & Informed Consent for Minors Form

Agreement for Service/Informed Consent for Minors

Introduction

Policy Regarding Consent for the Treatment of a Minor

Therapist generally requires the consent of both parents prior to providing any services to a minor child. If both parents are not in agreement about treatment, it may diminish the effectiveness of such treatment. It is your responsibility to notify the other parent that you are initiating psychotherapy/counseling within a reasonable amount of time. You may, additionally, be asked to provide supporting legal documentation, such as a custody order, prior to commencement of services.

Risks and Benefit of Therapy

A minor client will benefit from psychotherapy when his/her parents, guardians or other caregivers are supportive of the therapeutic process. Psychotherapy is a process in which Therapist and Client and sometimes other family members, discuss a myriad of issues, events, experiences and memories for the purpose of creating positive change so Client can experiences his/her life more fully. Therapy provides an opportunity to better and more deeply understand oneself, as well as any problems or difficulties Client may be experiencing. Psychotherapy is a joint effort between Client and Therapist. Process and success may vary depending upon the particular problems or issues being addressed, as well as many other factors. Participating in therapy may result in a number of benefits to Client, including, but not limited to, reducing stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviors, improved interpersonal relationships, increased comfort in social, school and family settings and increased self-confidence. Such benefits may also require substantial effort on the part of Client, as well as his/her caregivers and/or family members, including an active participation in the therapeutic process, honesty, and a willingness to change feelings, thoughts and behaviors. There is no guarantee that therapy will yield any or all of the benefits listed above. Participating in therapy may also involve some discomfort, including remembering and discussing unpleasant events, feelings and experiences. This discomfort may also extend to other family members, as they may be asked to address difficult issues and family dynamics. The process may evoke strong feelings of sadness, anger, fear etc. There may be times in which Therapist will challenge the perceptions and assumptions of the client or other family members, and offer different perspectives. The issues presented by client may result in unintended outcomes, including changes in personal relationships. During the therapeutic process, many clients find that they feel worse before they feel better. This is generally a normal course of events. Personal growth may be easy and swift at times, but may also be slow and frustrating. Client/Representative should address any concern he/she has regarding progress with Therapist.

Professional Consultation

Professional consultation is an important component of healthy psychotherapy practice. As such, Therapist regularly participates in clinical, ethical and legal consultation with appropriate professional. During such consultation, Therapist will not reveal any personal identifying information regarding Client or Client’s family or caregivers.

Records and Record Keeping

Therapist may take notes during session and will also produce other notes and records regarding Client’s treatment. These notes constitute Therapist’s clinical and business records, which by law, Therapist is required to maintain. Such records are the sole property of Therapist. Therapist will not alter his/her normal record keeping process at the request of any client or representative. Should Client or Representative request a copy of Therapist’s records; such a request must be made in writing. Therapist reserves the right, under California law, to provide Client or Representative with a treatment summary in lieu of actual records. Therapist also reserves the right to refuse to produce a copy of the record to another treating health care provider. Representative will generally have the right to access the records regarding Client. However, this right is subject to certain exceptions, set forth in California law. Should Representative request access to Therapist’s records, such a request will be responded to in accordance with California law. Therapist will maintain Client’s records for ten years following termination of therapy, or when Client is 21 years of age, whichever is longer. However, after ten years, Client’s records will be destroyed in a manner that preserves Client’s confidentiality.

Confidentiality

The information disclosed by Client is generally confidential and will not be released to any third party without written authorization from Client or Representative, except where permitted by law. Exceptions to confidentiality include but are not limited to, reporting child, elder and dependent adult abuse, when a client makes a serious threat of violence towards a reasonably identifiable victim or when a client is dangerous to him/herself or the person or property of another. Representative should be aware that Therapist is not a conduit of information from Client. Psychotherapy can only be effective if there is a trusting and confidential relationship between Therapist and Client. Although Representative can expect to be kept up to date as to Client’s progress in therapy, she/he will typically not be privy to detailed discussions between Therapist and Client. However, Representatives can expect to be informed in the event of any serious concerns Therapist might have regarding the safety or well being of client, including suicidality.

Patient Litigation

Therapist will not voluntarily participate in any litigation or custody dispute in which Client or Representative and another individual or entities are parties. Therapist has a policy of not communicating with Representative’s attorney and will generally not write or sign letters, reports, declaration or affidavits to be used in Client’s or Representative’s legal matter. Therapist will generally not provide records or testimony unless compelled to do so. Should Therapist be subpoenaed or ordered by a court of law to appear as a witness in an action involving Client, Representative agrees to reimburse Therapist for any time spent for preparation, travel or other time in which Therapist has made herself available for such an appearance at Therapist’s usual and customary hourly rate is $500 for half day and $1000 for full day paid 7 days before appearance. In addition, Therapist will not make any recommendations as to custody or visitation regarding Client. Therapist will make efforts to be uninvolved in any custody dispute between Client’s parents.

Psychotherapist-Client Privilege

The information disclosed by Client is generally confidential and will not be released to any third party without written authorization from Client or Representative, except where permitted by law. Exceptions to confidentiality include but are not limited to, reporting child, elder and dependent adult abuse, when a client makes a serious threat of violence towards a reasonably identifiable victim or when a client is dangerous to him/herself or the person or property of another. Representative should be aware that Therapist is not a conduit of information from Client. Psychotherapy can only be effective if there is a trusting and confidential relationship between Therapist and Client. Although Representative can expect to be kept up to date as to Client’s progress in therapy, she/he will typically not be privy to detailed discussions between Therapist and Client. However, Representatives can expect to be informed in the event of any serious concerns Therapist might have regarding the safety or well being of client, including suicidality.

Fee and Fee Arrangements

The usual and customary fee is $130.00 per 45-minute session. Sessions longer than 50 minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust her fee. Representative will be notified of any fee adjustments in advance. From tine-to-time Therapist may engage in telephone contact with Client or Representative for purposed other than scheduling sessions. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for nay telephone calls longer that fifteen minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Client or Representative and with the advance written authorization of Client or Representative. Representative is responsible for payment of the agreed-upon fee (on a pro rata basis) for any telephone calls longer than 15 minutes. Therapist is not a contracted provider with any insurance company or managed care organization. Should Representative chose to use his/her insurance, Therapist will provide Representative with a statement, which Representative can submit to the third-party of his/her choice to seek reimbursement of fees already paid.

Cancellation Policy

Representative is responsible for payment of the agreed upon fee for any missed sessions. Representative is also responsible for payment of the agreed upon fee for any session which Representative failed to give Therapist at lease 24 hours notice of cancellation. Cancelations notice should be left on Therapist voice mail at 805.620.7172

Therapist Availability

Therapist’s office is equipped with a confidential voice mail that allows Client or Representative to leave a message at any time. Therapist will make every effort to return calls with 24 hours (or by the next business day), but cannot guarantee that calls will be returned immediately. 
Therapist is unable to provide 24-hour crisis service. In the event that Client is feeling unsafe or requires immediate medical or psychiatric assistance, Client or Representative should call 911, or go to the nearest emergency room.

Termination of Therapy

Therapist reserves the right to terminate therapy at his/her discretion. Reasons for termination include but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, Client needs outside the Therapist’s scope of practice or competence, or Client is not making adequate progress in therapy. Client or Representative has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate, therapy, Therapist will generally recommend that Client participate in one or more termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. Therapist will also attempt to ensure a smooth transition to another therapist by offering referral when appropriate.

Acknowledgement

By sighing below, Representative acknowledges that he/she has reviewed and fully understands the terms and conditions of this agreement. Representatives had discussed such terms and conditions with Therapist and has had any questions with regard to its terms and conditions answered to Representative’s satisfaction. Representative agrees to abide by the terms and conditions of this agreement and consents to participate in psychotherapy with Therapist. Moreover Representative agrees to hold Therapist free and harmless from any claims, demands, or suits for damaged from injury or complications whatsoever, save negligence, that may result from such treatment.
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