Center For Individual & Family Therapy A Christian Counseling Center Family Forms (Page 2 of 6) in pdf

PARENTS AND NON-EMANCIPATED MINOR CLIENTS 12 years of age or older can consent to

psychological services subject to the involvement of their parents or guardian:

•

Unless the therapist determines that parental involvement would be detrimental.

•

A client over 12 years of age may independently consent to psychological services if he or she is

mature enough to participate intelligently in such services, and/or the minor client either would

present a danger of serious physical or mental harm to him or herself or others, or is the alleged

victim of incest or child abuse.

•

Clients over 12 years of age may independently consent to alcohol and drug treatment in some

circumstances.

•

Non-emancipated patients under 18 years of age and their parents should be aware that the law may

allow parents to examine their child’s treatment records unless the therapist determines that access

would have a detrimental effect on the professional relationship with the client, or to his/her physical

safety or psychological well-being.

•

It is our policy to request an agreement between minors (over 12 years of age) and their parents

about access to information. This agreement provides that during treatment, the therapist will

provide parents with only general information about the progress of the treatment, and the client’s

attendance at scheduled sessions. Therapists will encourage parent participation when appropriate.

PRE-LICENSED THERAPISTS:

I understand that my counselor is an:

MFT Trainee

MFT Intern

Associate Clinical Social Worker

Doctoral Student

Psychological Assistant

and therefore is not licensed, but is functioning under the supervision of his/her supervisor. I acknowledge

that my counseling will be reviewed and supervised weekly by a licensed supervisor. I understand that the

primary supervisor has full access to treatment records. I have received the business card of my therapist,

with the supervisor’s information.

______________________________________________ (therapist) working under the direct supervision of

__________________________________________________ (supervisor), have my permission to

audio/video-tape counseling sessions to be used for supervision purposes.

I understand that my sessions will be taped only with my knowledge, will be used only for supervision

purposes, and will be erased as soon as this purpose is fulfilled.

Client Initials________

TERMINATION OF THERAPY: It is to the client’s advantage that a decision to end therapy will be

discussed candidly and thoroughly with the therapist in advance of leaving. It is within the clients right to

terminate therapy at any time.

Please note that therapy may be a challenging process. During treatment it is possible that you may feel worse

before you begin to feel better. You therapist is available to discuss these issues anytime during your treatment.

Your signature below indicates that you have read this agreement and agree to its terms. Please

feel free to discuss any concerns you may have with your therapist or our Clinical Director at 714-558-9266

x953.

___

Client’s or Client Representative Signature

Date

Print Client’s Name

____________________

(If Representative, Print Name and Relationship to Client)

Client’s Signature

Date

Client’s Signature

Date

Print Client’s Name

Forms Consent to Consultation-Treatment

Center For Individual & Family Therapy A Christian Counseling Center Family Forms Page 2

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