Parental Permission To Treat A Minor (Page 2 of 8) in pdf

Parental Permission To Treat A Minor Page 2

Statement of Confidentiality

Maintaining confidentiality is very important to us at Kanawha Pastoral Counseling

Center. No information about you will be released to other parties without your written

permission. Limited information will be released to your insurance company as required.

We make every effort to protect your privacy; however, there are three occasions in

which all therapists are mandated by law to break confidentiality.

1) If a client indicates he/she is considering suicide the therapist will take

necessary action to help ensure the client’s safety. If the client is a minor,

his/her parent or guardian will be involved in the arrangement.

2) If a client indicates he/she is planning to harm another person, the therapist

will notify the proper authorities and/or the intended victim. If the client is a

minor, the parent or guardian will be involved.

3) If a client indicates he/she has knowledge of the abuse or neglect of a child, an

elderly person, or a person who is mentally or physically impaired, Child or

Adult Protective Services will be contacted. This may also be done without

your consent or knowledge.

By signing below, I acknowledge the statement of confidentiality and agree to the above.

_________________________________________

Client/Guardian

Date

________________________________________

Client/Guardian

Date

________________________________________

Client/Guardian

Date

________________________________________

Therapist

Date

Parental Permission To Treat A Minor Page 2