Jamie Vollmoeller, LCSW to provide psychotherapeutic treatment to our child,

(the “child”) and to include us, the parents, as necessary, as adjuncts in the child’s treatment.

While the parents can expect benefits from this treatment for the child, they fully understand that no particular outcome can be guaranteed. The parents understand that they are free to discontinue treatment of the child at any time but that it would be best to discuss with the psychotherapist any plans to end therapy before doing so.

The parents have fully discussed with the psychotherapist what is involved in psychotherapy and understand and agree to the policies about scheduling, fees and missed appointments. The discussion about therapy has included the psychotherapist’s evaluation and diagnostic formulation of the child’s problems, the method of treatment, goals and length of treatment, and information about record-keeping. The parents have been informed about and understand the extent of treatment, its foreseeable benefits and risks, and possible alternative methods of treatment. The parents understand that therapy can sometimes cause upsetting feelings to emerge, and that the child’s problems may worsen temporarily before improving.

The parents understand that the psychotherapist cannot provide emergency services. The psychotherapist has told the parents whom to call if an emergency arises and the psychotherapist is unavailable.

The parents understand that information about psychotherapy is almost always kept confidential by the psychotherapist and not revealed to others besides the parents unless a parent authorizes such release. There are few exceptions as follows:

  1. The psychotherapist is required by law to report suspected child abuse or neglect to the proper authorities. The psychotherapist is also mandated to report authorities patients who are at imminent risk of harming themselves or others for the purpose of those authorities checking to see whether such patients are owners of firearms, and if they are or apply to be, then limiting possibly removing their ability to possess them.

  2. If a child tells the psychotherapist that he or she intend to harm another person, the psychotherapist must try to protect that person, including by telling the police or person or other health care providers. Similarly, if the child threatens to harm him or herself, or a child’s life or health is in any immediate danger, the psychotherapist will try to protect the child, including, as necessary, by telling the police or other health care providers, who may be able to assist in protecting the child.

  3. If a child is involved in certain court proceedings the psychotherapist may be required by law to reveal information about the child’s treatment. These situations include child custody disputes, vases where therapy patient’s psychological condition is an issue, lawsuits or formal complaints against the psychotherapist, civil commitment hearings, and court-related treatment.

  4. If the parents’ and child’s health insurance or managed care plan will be reimbursing me or paying the psychotherapist directly, they will require that confidentiality be waived and that the psychotherapist give them information about the child’s treatment.

  5. The psychotherapist may consult with other healthcare professionals about the child’s treatment, but in doing so will not reveal the child’s name or other information that might identify the child, unless specific consent to do so is obtained from the parent. Further, when the psychotherapist is away or unavailable, another psychotherapist might answer calls and so will need to have some information about the child’s treatment.

  6. If an account with the psychotherapist becomes overdue and responsible parties do not work out a payment plan, the psychotherapist will reveal a limited amount of information about a patient’s treatment in taking legal measures to be paid. This would include the child’s and parents’ names, social security number, address, dates and type of treatment and the amount due.

In all of the situations described above the psychotherapist will try to discuss the situation with a parent before any confidential information is revealed, and will reveal only the least amount of information that is necessary.

The parents, as legal guardians of the child, have rights to general information about what takes place in the child’s therapy, to information about the child’s progress in therapy, to information about any dangers the child might present to self or others, and, upon request, to obtain copies of the child’s treatment record (with certain qualifications and exceptions). The parents understand that it is usually best not to ask for specific information about what was said in therapy sessions because this might break the trust between the child and the psychotherapist, especially for children over the age of 12.

The parents agree that in the event custody of, or visitation with, the child is contested in a legal proceeding, neither the parents nor their attorneys will require the psychotherapist to testify at any proceedings, because to do so would hurt the child’s treatment, because the psychotherapist’s role is a therapeutic and not evaluative one, and because other forensic professionals would be better able and more appropriate to conduct any necessary evaluation. Because of these limitations, the psychotherapist also will not be able to give any opinion regarding custody, visitation or any other legal issue. If such a proceeding does occur, the parents agree that the psychotherapist’s role will be limited to providing to a mental health professional appointed to perform such an evaluation, and/or to the attorneys, law guardian, if any, and the judge involved in the legal proceeding, written information regarding, and/or the record of, the child’ treatment; the psychotherapist will provide these either as required by law or upon the authorization of either parent.

The psychotherapist has explained to the parents that children with two parents have the best chance to benefit from therapy if both parents are involved and cooperate with each other and the psychotherapist. If both of a child’s parents are consenting to therapy:

*Each of us agrees that he or she will not end the child’s therapy without the agreement of the other parent, and that if we disagree about the child’s continuing in therapy, we will try to come to an agreement, by counseling if necessary, before ending the child’s therapy.

*We each agree to cooperate with the treatment plan of the psychotherapist for the child and understand that without mutual cooperation, the psychotherapist may not be able to act in the child’s best interests and may have to end therapy.

*We agree that each of us has and shall continue to have the right to information about the child’s treatment and the treatment records of the psychotherapist regarding the child, and agree that the psychotherapist may release information or records to either of us without any additional authorization of the other.

*We agree that each of us has and shall continue to have the right to information about the child’s treatment and the treatment records of the psychotherapist regarding the child, and agree that the psychotherapist may release information or records to either of us without any additional authorization of the other.

The parents understand that I have a right to ask the psychotherapist about the psychotherapist’s training and qualifications and about where to file complaints about the psychotherapist’s professional conduct.

By signing below the parents are indicating that they have read and understood this agreement, that they give consent to the psychotherapist’s treatment of the child, and that they have the proper legal status to give consent to therapy for the child.