adolescent informed consent and privacy

Privacy Of Information Shared In Counseling/Therapy:  Your Rights  

 Information discussed in counseling will remain private and confidential.  However confidentiality cannot be maintained when: 

• You plan to cause serious harm or death to yourself, and I believe you have the intent and ability to carry out this threat in the very near future. If that is the case, I must take steps to inform a parent or guardian of what you have told me. It is my legal and ethical responsibility to make sure that you are protected from harming yourself.  

• You plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future. In this situation, I am legally required to inform your parent or guardian, and I must inform the person whom you intend to harm.  

• You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed.  

• You tell me that you are being abused-physically, sexually or emotionally-or that you have been abused in the past. In this situation, I am required by law to report the abuse.  

• You are involved in a court case and a request is made for information about your counseling or therapy. If this happens, I will not disclose information without your written agreement unless the court requires me to do so. I will do all that I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening. 

COMMUNICATING WITH YOUR PARENT (S) OR GUARDIAN (S):  

Except for situations such as those mentioned above, I will not tell your parent or guardian specific things you share with me in our private therapy sessions. This includes activities and behavior that your parent/guardian may not approve of — or would be upset by — but that do not put you at risk of serious and immediate harm. 

However, if your risk-taking behavior becomes more serious, then I will need to use professional judgment to decide whether you are in serious and immediate danger of being harmed. If I feel that you are in such danger, I will communicate this information to your parent or guardian and I will inform you that I am doing so. 

If I have agreed to keep information confidential – to not tell your parent or guardian – and I come to believe that it is important for them to know what is going on in your life, I will encourage you to tell your parent/guardian and will help you find the best way to tell them. 

Also, when meeting with your parents, I may sometimes describe problems in general terms, without using specifics, in order to help them know how to be more helpful to you.  

ADOLESCENT THERAPY CLIENT:  

Signing below indicates that you have reviewed the policies described above and understand the limits to confidentiality. If you have any questions as we progress with therapy, you can ask me at any time.  

Minor’s Signature _______________________________________ Date __________  

PARENT/GUARDIAN:  

Check box and sign below indicating your agreement to respect your  adolescent’s privacy:  

[  ] I will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I will be provided with periodic  updates about general progress, and/or may be asked to participate in therapy sessions as needed.  

[  ] I understand that I will be informed about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment and may sometimes be made in confidential consultation with her consultant/supervisor.  

Parent Signature ___________________________________ Date _______

Parent Signature ___________________________________ Date ________