Child Intake Documents I And Ii (Page 4 of 4) in pdf

II. Consent for Child Treatment

I, the undersigned, voluntarily agree to allow my child to participate in counseling services. I

understand that these services may be in the form of individual or family therapy. I also understand that any

information obtained will be held in the strictest of confidence, except as stipulated by the State of Oklahoma

and the Health Insurance Portability and Accountability Act (HIPAA), as described in the Privacy Notice.

I recognize that I have the right to withdraw my child from therapy at any time, without prejudice,

which could void this consent for counseling. I understand that I will be given the opportunity to ask questions

about the foregoing to my satisfaction.

I have also been provided with a copy of the office policies, client responsibilities, and privacy notice,

or have accessed them on the website and agree to abide by them.

In cases of divorce or parental conflict I agree to not request Kathy McDonald’s participation in any court

proceedings, including but not limited to: testifying, providing records, or writing letters of summary or

recommendation.

I have a legal right to: ( ) sole ( ) shared medical decision making regarding the following child

Name of Child

The following documents are available on the website

https://

You may receive a hard copy, if requested. The information listed will be reviewed before

services begin. Please check that yes, you have accessed these forms on the website or in hard

copy from Kathy McDonald:

Yes ( ) No ( ) I have received the Office Policies and General Information

Yes ( ) No ( ) I have received the Client’s Rights and Responsibilities

Yes ( ) No ( ) I have received the Notice of Privacy Practices

Yes ( ) No ( ) I have been given the opportunity to ask questions which have been answered to my satisfaction.

I understand that I may revoke consent to treat my child by submitting my request in writing to Kathy

McDonald, Ph.D., LPC-S, NCC.

Parent/Legal Guardian Signature: ________________________________________

Date: ___________

Parent/Legal Guardian Signature: __________________________________________

Date:____________

Child Intake Documents I And Ii Page 4