Co-Parenting Solutions, LLC

9. Consent for Minor Therapeutic Treatment

Welcome to my practice. This document contains important information about my professional services. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.


Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, your child has certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your child’s therapist, have corresponding responsibilities. These rights and responsibilities are described below.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your child’s
life. However, psychotherapy has been shown to have benefit in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will
happen. Psychotherapy requires a very active effort on the part of the client, your child. In order to be most successful, your child will have to work on things we discuss outside of sessions.

Generally, the first two sessions will involve a comprehensive evaluation of your child’s needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable having your child work with me. If you have questions about my procedures, we should discuss them whenever those questions arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.


My policies about confidentiality, as well as other information about privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been offered a copy with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.


While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 13 unless s/he agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child’s authorization, unless I feel there is a safety concern (see also above section on Confidentiality for exceptions), in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections.

Parent/Guardian: Initial the points below and include your signature at the bottom to indicate 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 know I have the legal right to request written records/session notes since my child is a minor, which disclosure may be limited by law under certain circumstances, 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 seriously endanger my child. I know the decision to disclose information in these circumstances is up to the therapist’s professional judgment.


Your signature below indicates that you have read this Agreement, have had your questions answered and had the opportunity to read the Notice of Privacy Practices and agree to their terms.

Date Signed:
Client Name:
Minor Name:  
Additional Minor Names:
Client Relationship to Minor:  

Revised 12/2019

Leave this empty:

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Signature Certificate
Document name: 9. Consent for Minor Therapeutic Treatment
lock iconUnique Document ID: 228653fb7c2bc7b7353822a1ce275eb8840850a4
Timestamp Audit
July 24, 2020 2:37 pm EDT9. Consent for Minor Therapeutic Treatment Uploaded by Jordana Wolfson - IP
August 18, 2020 10:08 am EDT Document owner has handed over this document to 2020-08-18 10:08:24 -