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Intake E. Agreement Regarding Minors
LifeBack
4 Princess Rd
Suite 206
Lawrenceville, New Jersey 08648
Phone 609-482-3701
Fax 609-482-3702
Client Information
First Name:
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Last Name:
*
Date of Birth:
*
Birth Sex:
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The involvement of children and adolescents in therapy can be highly beneficial to their overall development. Very often, it is best to see them with parents and other family members; sometimes they are best seen alone. I will assess which might be best for your child and make recommendations to you. Obviously, the support of all the child's caregivers is essential, as well as their understanding of the basic procedures involved in counseling children.
The general goal of involving children in therapy is to foster their development at all levels. At times, it may seem that a specific behavior is needed, such as to get the child to obey or reveal certain information. Although those objectives may be part of overall development, they may not be the best goals for therapy. Again, I will evaluate and discuss these goals with you.
Because the therapist's role is that of the child's helper, I will not become involved in legal disputes or other official proceedings unless compelled to do so by a court of law. Matters involving custody and mediation are best handled by another professional who is specially trained in those areas rather than by the child's therapist.
The issue of confidentiality is critical in treating children. When children are seen with adults, what is discussed is known to those present and should be kept confidential except by mutual agreement. Children seen in individual sessions (except under certain conditions) are not legally entitled to confidentiality (also called privilege); their parents have this right. However, unless children feel they have some privacy in speaking with a therapist, the benefits of therapy may be lost. Therefore, it is necessary to work out an arrangement in which children feel that their privacy is generally being respected, at the same time that parents have access to critical information. This agreement must have the understanding and approval of the parents or other responsible adults and of the child in therapy.
This agreement regarding treatment of minors has provisions for inserting individual details., which can be supplied by both the child and the adults involved. However, it is first important to point out the exceptions to this general agreement. The following circumstances override the general policy that children are entitled to privacy while parents or guardians have a legal right to information.
• Confidentiality and privilege are limited in cases involving child abuse, neglect, molestation, or danger to self or others. Inthese cases, the therapist is required to make an official report to the appropriate agency and will attempt to involve parents as much as possible.
• Minors may independently enter into therapy and claim the privllege of confidentiality in cases involving abuse or severe neglect, molestation, pregnancy, or communicable diseases., and when they are on active military duty, married, or officially emancipated. They may seek therapy independently for substance abuse, danger to self or others, or a mental disorder, but parents must be involved unless doing so would harm the child.
• Any evaluation, treatment, or reports ordered by or done for submission to a third party, such as a court or a school, is not entirely confidential and will be shared with that agency with your specific vvritten permission. Please also note that I do not have control over information once it is released to a third party.
Now that the various aspects surrounding confidentiality have been stated, the specific agreement between you and your child/children follows:
I, (name)
Relationship to Child
I, (name)
Relationship to Child
agree that my/our child/children: (names)
should have privacy in his/her/their therapy sessions, and I agree to allow this privacy except in extreme sihlations, which I will discuss with the therapist. At the same time, except under unusual circumstances, I understand that I have a legal right to obtain this information.
To increase the effectiveness of the therapy, I agree to the following;
I will do my best to ensure that therapy sessions are attended and will not inquire about the content of sessions. If my child prefers/children prefer not to volunteer information about the sessions, I will respect his/her/their right not to disclose details. Basically, unless my child has/children have been abused or is/are a clear danger to self or others, the therapist will normally tell me only the following:
• whether sessions are attended
• whether my child is/children are generally participating or not
The normal procedure for discussing issues that are in my child's/children’s therapy will be joint sessions including my child/children, the therapist, and me and perhaps other appropriate adults. If I believe there are significant health or safety issues that I need to know about, I will contact the therapist and attempt to arrange a session with my child/children present. Similarly; when the therapist determines that there are significant issues that should be discussed with parents; every effort will be made to schedule a session involving the parents and the child/children. I understand that if information becomes known to the therapist and has a significant bearing on the child's/children' swell-being, the therapist will work with the person providing the information to ensure that both parents are aware of it. In other words; the therapist will not divulge secrets except as mandated by law; but may encourage the individual who has the information to disclose it for therapy to continue effectively.
Patient goals will be determined by treatment provider(s) and patient during the development of their treatment plan.
Adolescent Consent to Treatment
PA Ages 14 and Up
NJ Ages 16 and Up
The law affords adolescents and young adults the right to consent to mental health counseling and treatment without parental consent regardless of whether the patient is covered under the insurance policy of the patient's parent or legal guardian. In compliance with this law, Lifeback will not release to your parent(s) or legal guardian(s) any protected health information (as defined by the Health Insurance Portability and Accountability Act of 1996 - as amended) about you without your consent except where such release is required by law. This law does not, however, cover the administration of medication to adolescents.
If you are covered under your parent's insurance policy, we will send a copy of this notice to your parent's insurer along with your bill. Your insurance provider may send payment for Lifeback's services to the policy holder on your insurance, which may be your parents or guardian. In an effort to collect such payment, Lifeback may contact your parents or guardian regarding any insurance checks sent to them, but Lifeback will not discuss the reason for your treatment with your parents, guardant, or other third part to whom the check is sent. By signing below, you consent to have Lifeback contact the policy holder of your insurance coverage for the purpose of collecting payment checks only.
This form explains Lifeback's policy only, and does not guaranty compliance by your parent's insurance provider. Lifeback recommends that, in addition to completing this form, you contact your parent's insurance provider and request that your information be kept confidential and separate from the policy holder. Please contact us if you have any questions.
Parent(s): Please make any additions or modifications as desired
Parent/Guardian of Minor Signature
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Minor Signature (not required)
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