Print Friendly, PDF & Email

Consent Form

THERAPY FOR CHILDREN AND ADOLESCENTS

INFORMED CONSENT FOR CHILDREN/ADOLESCENTS

The purpose of this form is to share some important principles, which guide my therapeutic practice so that your decision to place your child/adolescent into therapy with me can be based on accurate, informed expectations. Please read this carefully and feel free to ask any questions about what you have read if you need further clarification.

CONFIDENTIALITY

In general one of the most important rights the person seeking therapy has involves confidentiality, even if it is a young child.  Information revealed by a client during the sessions will be kept strictly confidential and will not be revealed to any other person or agency without written permission, with the following exceptions:

In order to maintain professionalism therapists are required to be supervised by another therapist during these interactions, client anonymity is paramount.

Confidentiality has some legal limits as well. There are situations where the therapist can be required to reveal information obtained during therapy to another person without the parent or child’s permission. These situations involve harm to self, harm to others and any safeguarding concerns. Whenever possible the child/adolescent will be informed before these concerns are shared

CHILDREN AND CONFIDENTIALITY

Therapists who work with children have the difficult task of protecting the child/adolescents right to privacy while at the same time respecting the parent’s or guardian’s right to information.

Therapy is most effective when a trusting relationship exists between the therapist and the child. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better relationship between children/adolescents and their parents. However, it is often necessary for children to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy.

It is useful if you do not ask your child or adolescent what they discussed after each session. However, if they wish to share anything with you that is their choice but they should not feel pressurised to do so.

If it is necessary to refer your child to another mental health professional with more specialised skills, I will share that information with you and recommend an appropriate referral.

I will not share with you what your child/adolescent has disclosed with me without your child’s/adolescent’s consent. (However, this is not applicable if it is a safeguarding concern). At the end of your child’s/adolescent’s treatment, it may be helpful to review the sessions in general.

THERAPUETIC RELATIONSHIP

It is helpful to remember that our relationship is professional and not social. Our professional relationship is of utmost importance as we work together towards achieving your goals and bringing resolution and healing to your child/adolescents life. If you have any concerns regarding your child/adolescent during the therapeutic process, please email me at info@akidspace.co.uk. I am available Monday to Friday from 9am to 5pm and will respond to you as soon as I can.  Please understand that my therapeutic relationship is with your child/adolescent and therefore I cannot keep any concerns that you share with me from your child/adolescent.

ENDINGS

Both you and your child or adolescent are in compete control and may end the therapeutic relationship at any time. Endings are an important part of the therapeutic process, in order to manage an ending appropriately with your child/adolescent I require at least two weeks notice prior to an ending.

FEES AND APPOINTMENTS

Payable by cash or cheque at the end of each session. If you wish to pay by bank transfer please do so before the start of each session. I will supply you with my bank details prior to the first session.

EMERGENCIES

Please understand that I am not a crisis service. In the event of an emergency pls contact your GP or go to your local A&E or call 999.

CANCELLATION

Please contact me if you discover that your child/adolescent will not be able to keep an appointment. I require 48 hours notice of cancellation. if the appointment is not cancelled within the 48 hour period I would expect the full fee of the missed appointment.

DATA PROTECTION

The only data I collect is name, address, email and telephone number of the parent/carer of the child or young person that I am working with. I am obliged to keep notes of the key issues that is discussed during the sessions and they will be kept for six years, then they will be destroyed by a shredder.

ACKNOWLEDGEMENT AND CONSENT

By your signature below, you are indicating that you read and understood this consent form and that any questions you had about this consent form were answered to your satisfaction.

Parent/Guardian’s name(s) (please print)

 ……………………………………………………………….

………………………………………………………………..

Date: ……………………………………………………….

Parent/Guardian’s Signature(s)

……………………………………………………………….

 ………………………………………………………………

Date: ……………………………………………………..

FIRST PARENT/CARER CONTACT INFORMATION

I confirm that I have read and understand the consent form and agree to the above and that my son/daughter under the age of 18 may be treated as a client by Emma Cohn

Name of child: ……………………………………………….

Referred by: ———————————–

Your name: ………………………………………………………….

Relationship to child:—————————

Address:……………………………………………………………….

………………………………………………………………………………

Contact Number:…………………………………………………

Email address:…………………………………………………….

SECOND PARENT/CARER INFORMATION (IF APPLICABLE)

Name of child: ………………………………………………..

Your name: ………………………………………………………….

Relationship to child:—————————

Address:……………………………………………………………….

……………………………………………………………………………….

Contact Number:…………………………………………………..

Email address:……………………………………………………….

MEDICAL INFORMATION

Any diagnosed conditions of child/adolescent:

……………………………………………………………………………….

Print Friendly, PDF & Email