informed consent for minors
pet loss dc
Jessica Kwerel, LPC, LCPC
www.petlossdc.com
jessica@petlossdc.com
(202) 335-3019
Psychotherapy and coaching with people of any age relies on the client’s confidence that what is shared with the therapist is private and confidential. While parents and guardians have a right to know general information about how therapy with their child is progressing, in signing this form you waive the right to know the private details of the child’s therapy, or to have access to the confidential therapy records of the child. A general summary can be provided at any time upon request.
Information provided within the counseling relationship will be strictly confidential. However, exceptions to confidentiality include the following:
If there is a danger to self or others. Confidentiality may be broken in order to protect self or other from harm.
Suspected cases of child abuse or neglect; suspected cases of abuse or neglect of an elder or an adult who is disabled. By law, information suggesting possible abuse or neglect must be reported to law enforcement or DC’s Child and Family Services Agency.
Instances where the court shall order the disclosure of otherwise privileged information.
Information regarding diagnosis, treatment plan, etc. will be provided to insurance companies (if applicable) unless otherwise specified.
In response to a subpoena for these records.
In some instances it is helpful to consult with another therapist regarding the treatment of a client.
By signing this form, I understand and agree to the above information. I also confirm that I am the legal guardian for the below named minor.