Child & Adolescent Services
Child & Adolescent Consent Acknowledgement
Please review the following overview and sign the C & A consent acknowledgement below (new & current clients only):
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1. Dual Parental/legal guardian Acknowledgement:
- Both parents/legal guardians must sign the acknowledgement for their child to receive mental health services.
- A PDF copy of the full consent, signed within our Electronic Health Record (EHR), can be provided upon request.
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2. Custody Verification:
- If separated or divorced, please provide the most recent custody decree demonstrating your authority to
authorize treatment for your child.
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3. Zone of Privacy:
- To foster a trusting therapist-child relationship, we share general information about your child's treatment.
- Specific details disclosed by your child during sessions will not be shared without your child's consent.
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4. Accessing Records:
- The "zone of privacy" extends to treatment records.
- By signing, you waive your right to access your child's treatment records, but a treatment summary can be
provided upon request.
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5. Adolescence Autonomy:
- Adolescents may share sensitive information; confidentiality is maintained unless there's imminent harm risk.
- You'll be informed of missed sessions or if a referral to another mental health professional becomes necessary.
6. Legal Disputes:
- Clinicians won't be involved in legal disputes, especially custody, or visitation matters.
- Clinicians won't testify in court, respecting ethical boundaries regarding not providing opinions on custody or
visitation suitability.
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7. Legal Fees:
- In the event of clinician involvement in legal disputes, the responsible party agrees to reimburse at $200/hour
for testimony, attendance, and any case-related costs.
- Additional fees apply for report preparation, consultation or supervision, telephone calls, and travel time at the
same rate.
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