Quantcast

Child Therapy Contract Form

Child Therapy Contract

Prior to beginning treatment, it is important for you to understand our approach to child therapy and agree to some rules about your child’s confidentiality during the course of his/her treatment. The information herein is in addition to the information contained in the Patient-Therapist Agreement. Under HIPAA and the APA Ethics Code, we are legally and ethically responsible to provide you with informed consent. As we go forward, we will try to remind you of important issues as they arise.

One risk of child therapy involves disagreement among parents and/or disagreement between parents and the therapist regarding the best interests of the child. If such disagreements occur, your therapist will strive to listen carefully so that the therapist can understand your perspectives and fully explain his/her perspective. We can resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress. Ultimately, you will decide whether therapy will continue. If either parent decides that therapy should end, Corner Canyon Counseling and Psychological Services will honor that decision, however, we ask that you allow us the option of having a few closing sessions to appropriately end the treatment relationship.

Therapy is most effective when a trusting relationship exists between the psychologist/therapist and the patient. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better relationship between children 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. By signing this agreement, you will be waiving your right of access to your child’s treatment records.

It is our policy to provide you with general information about treatment status. We will raise issues that may impact your child either inside or outside the home. If it is necessary to refer your child to another mental health professional with more specialized skills, we will share that information with you. We will not share with you what your child has disclosed to your therapist without your child’s consent. Your child’s therapist will tell you if your child does not attend sessions. At the end of your child’s treatment, your child’s therapist will provide you with a treatment summary that will describe what issues were discussed, what progress was made, and what areas are likely to require intervention in the future.

If your child is an adolescent, it is possible that he/she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of normal adolescent experimentation, but at other times they may require parental intervention. We must carefully and directly discuss your feelings and opinions regarding acceptable behavior. If your child’s therapist ever believes that your child is at serious risk of harming him/herself or another, the therapist will inform you.

Although our responsibility to your child may require involvement in conflicts between the two of you, we need your agreement that the involvement will be strictly limited to that which will benefit your child. This means, among other things, that you will treat anything that is said in session with your child’s therapist as confidential. Neither of you will attempt to gain advantage in any legal proceeding between the two of you from our involvement with your child/children. In particular, we need your agreement that in any such proceedings, neither of you will ask the therapist to testify in court, whether in person, or by affidavit. You also agree to instruct your attorneys not to subpoena your child’s therapist or to refer in any court filing to anything the therapist has said or done.

Note that such agreement may not prevent a judge from requiring the therapist’s testimony, even though we will
work to prevent such an event. If the therapist is required to testify, we are ethically bound not to give opinions about either parent’s custody or visitation suitability. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, we will provide information as needed (if appropriate releases are signed or a court order is provided), but the therapist will not make any recommendation about the final decision. Furthermore, if the therapist is required to appear as a witness, the party responsible for my participation agrees to reimburse me at the rate of $250 per hour for time spent traveling, preparing reports, testifying, being in attendance, and any other case-related costs.

Abbreviated Contract Draft

  • If you decide to terminate treatment, Corner Canyon Counseling and Psychological Services has the option of
    having a few closing sessions with your child to properly end the treatment relationship.
  • You are waiving your right to access to your child’s treatment records.
  • Your child’s therapist will inform you if your child does not attend the treatment sessions.
  • At the end of treatment, your child’s therapist will provide you with a summary that includes a general description
    of goals, progress made, and potential areas that may require intervention in the future.
  • If necessary to protect the life of your child or another person, your child’s therapist has the option of disclosing
    information to you without your child’s consent.
  • You agree that our role is limited to providing treatment and that you will not involve me the child’s therapist any
    legal dispute, especially a dispute concerning custody or custody arrangements (visitation, etc.).
  • You also agree to instruct your attorneys not to subpoena your child’s therapist or to refer in any court filing to
    anything the therapist has said or done.
  • If there is a court appointed evaluator, and if appropriate releases are signed and a court order is provided, the
    therapist will provide general information about the child which will not include recommendations concerning
    custody or custody arrangements.
  • If for any reason, your child’s therapist is required to appear as a witness, the party responsible for my
    participation agrees to reimburse me at the rate of $250 per hour for time spent traveling, preparing reports,
    testifying, being in attendance, and any other case-related costs.
  • Your signature below indicates that you have read the information in this document and agree to abide by its terms
    during our professional relationship.
    YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO
    SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.
    By typing your name you have created an electronic signature as legally binding as your handwritten signature.

    Signature of Legal Guardian:
    First Name:
    Last Name:
    Date (if you are having troubles with the date not submitting use the following format yyyy/mm/dd)

    Signature of Legal Guardian (In cases of divorce, if legal custody is shared, both parents must sign)
    First Name:
    Last Name:
    Date (if you are having troubles with the date not submitting use the following format yyyy/mm/dd)

Phone: 801.438.6059 | Fax: 801.501.0249

Draper Office

248 East 13800 South, #4
Draper, UT 84020
801.438.6059

Bluffdale Office

14241 South Redwood Road Suite 100
Bluffdale, UT 84065
801.610.1573