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Parent Authorization for Minor's Mental Health Treatment
Jewish Family and Career Services of Atlanta
4549 Chamblee Dunwoody Road
Phone 770.677.9389
Fax 770.677.9400
Client Information
First Name:
*
Last Name:
*
Date of Birth:
*
Birth Sex:
*
Address:
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In order to authorize mental health treatment for your child, you must have either sole or joint legal custody of your child. If you are separated or divorced from the other parent of your child, please notify me immediately. I will ask you to provide me with a copy of the most recent custody decree that establishes custody rights of you and the other parent or otherwise demonstrates that you have the right to authorize treatment for your child.
If you are separated or divorced from the child's other parent, please be aware that it is my policy to notify the other parent that I am meeting with your child. I believe it is important that all parents have the right to know, unless there are truly exceptional circumstances, that their child is receiving mental health evaluation or treatment.
One risk of child therapy involves disagreement among parents and/or disagreement between parents and the therapist regarding the child's treatment. If such disagreements occur, I will strive to listen carefully so that I can understand your perspectives and fully explain my perspective. We can resolve such disagreements or we can agree to disagree, so long as this enables your child's therapeutic process.
Ultimately, parents decide whether therapy will continue. If either parent decides the therapy should end, I will honor that decision, unless there are extraordinary circumstances. In most cases, however, I will request that you allow me the option of having a few closing sessions with your child to appropriately end the treatment relationship.
Individual Parent/Guardian Communications with Me
In the course of my treatment of your child, I may meet with the child's parents/guardians either separately or together. Please be aware, however, that, at all times, my patient is your child - not the parents/guardians or any siblings or other family members of the child will be identified therapy clients with rights of psychological privilege unless a written contract is made to conduct family therapy mutually agreed upon by the therapist and the parents.
If I meet with you or other family members in the course of your child's treatment, I will make notes of that meeting in your child's treatment records. Please be aware that those notes will be available to any person or entity that has legal access to your child's treatment record as mandated by law.
Mandatory Disclosures
In some situations, I am required by law or by the guidance of my profession, to disclose information, whether or not I have your or your child's permission. I have listed some of these situations below.
Confidentiality cannot be maintained when:
Child patients tell me they plan to cause serious harm or death to themselves, and I believe they have the intent and ability to carry out this threat in the very near future. I must take steps to inform a parent or guardian or others of what the child has told me and how serious I believe this threat to be and to try to prevent the occurrence of such harm.
Child patients tell me they plan to cause serious harm or death to someone else, and I believe they have the intent and ability to carry out this threat in the very near future. In this situation, I must inform a parent or guardian or others, and I may be required to inform the person who is the target of the threatened harm (and the police).
Child patients are doing things that could cause serious harm to themselves or someone else even if they do not intend to harm themselves or another person. In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed.
Child patients tell me, or I otherwise learn that, it appears that a child is being neglected or abused physically, sexually or emotionally - or that it appears they have been neglected or abused in the past. In these situations, I am required by law to report the alleged abuse or neglect to the appropriate state child protective agency.
I am ordered by a Court to disclose information with proper releases or other exceptions.
Disclosure of Minor's Treatment
Therapy is most effective when a trusting relationship exists between the therapist and the patient. Privacy is especially important in earning and keeping that trust. As a result, it is essential for children to have a "zone of privacy" where they feel free to discuss personal matters without fear that their thoughts and feelings will be immediately communicated to their parents. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy.
It is my policy to provide you with general information about your child's treatment, but NOT to share specific information that your child has disclosed to me without your child's agreement. This includes activities and behavior that you would not approve of - or might be upset by - but that do not put your child at risk of serious and immediate harm. However, if your child's risk-taking behavior becomes more serious, I will need to use my professional judgement to decide whether your child is in serious and immediate danger of harm. If I feel that your child is in such danger, I will communicate this information to you.
You can always ask me questions about the type of information I would disclose. You can ask in the form of "hypothetical situations," such as: "If a child told you they were doing __________________, would you tell the parents?"
Even when we have agreed to your child's treatment information confidential from you, I may believe that it is important for you to know about a particular situation occurring in your child's life. In these situations, I will encourage your child to tell you, and I will help your child find the best way to do so. Also, when meeting with you, I may sometimes describe your child's problems in general terms, without using specifics, in order to help you know how to be more helpful to your child.
Disclosure of Minor's Treatment Records to Parents
Although the laws of the State of Georgia may give parents the rights to see any written records I keep about your child's treatment, by signing this agreement, you are agreeing that your child should have a "zone of privacy" in their meetings with me and you agree to not request access to your child's written treatment records unless ordered by a Court or to transfer the record to another therapist who is serving your child.
As provided elsewhere in this Informed Consent, I do not wish to be involved in the legal system or to speak with anyone regarding testifying in Court. If I am required to testify, I am ethically bound NOT to give my opinion about either parent's custody, visitation suitability, or fitness. Furthermore, if I am required to appear as a witness or to otherwise perform work related to a legal matter, the party responsible for my participation agrees to reimburse me for those amounts stated otherwise in this Informed Consent.
Parent/Guardian of Minor Patient:
Please initial after each line and sign below indicating your agreement to respect your child's privacy:
_____ _____ 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 may have 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 child's treatment.
_____ _____ I understand that I will be informed about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to the therapist's professional judgment, unless otherwise noted above.
Signature
Signer Type:
Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
Name:
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Signature
Signer Type:
Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
Name:
Sign with Touch
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