Counselling Informed Consent - Children
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INFORMED CONSENT FOR CHILD CLIENT -   Welcome to the Informed Consent document. Integrative Counselling does not provide opinions, evaluations, diagnosis, or assessments for mental health, legal, or work related issues. Additionally, services will not involve any form of custody or access assessment. The client will be referred to a third party to fulfill these needs. Your counsellor is a member of the Alberta College of Social Work and follows a code of ethics set out by this body. Please fill in all boxes. *
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CONFIDENTIALITY - The principle of confidentiality is a keystone of counselling, which helps to build a unique therapeutic relationship with a therapist, and provide a safe space to share thoughts, concerns, and hopes. Children, much like adults, can also have complex, private, emotional lives, which therapists want to honour and protect through the principle of confidentiality. *
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WHAT DOES THIS MEAN AS A PARENT? - As therapists, and parents ourselves, we know feeling shut out can be hard! Especially when all you want to do is be present for your child, and help.  However, parents / guardians are encouraged to give their child the opportunity to engage in the therapeutic process, allowing the child to bring their experience to you if they choose, vs. seeking session details from the therapist or child. This type of support can increase a child's sense of independence, autonomy, and trust in both the therapeutic environment, and at home. *
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CONFIDENTIALITY BENEFITS - 1) Building and preserving a strong therapeutic alliance.  2) Increasing cooperation in treatment: A child has little reason to disclose information if there is no guarantee of confidentiality.  3) Ensuring a child gets effective treatment: If a child cannot disclose what they want, the therapist may not have enough information to know how to help.  4) Improving the parent-child relationship: Some parents may worry that “secrets” will undermine their relationship with their child. But when a child can openly discuss their feelings in therapy, their relationship with others, including their parents, may improve. *
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LIMITATIONS OF CONFIDENTIALITY - Confidentiality may be a keystone of counselling, but so is the health and safety of a child. Serious health and safety issues ethically require a therapist to inform a parent/guardian in order to support, protect, and bring in additional help. You will always be kept informed if your child's safety is in question! *
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Limitations to confidentiality arise when there is concern regarding 1) If your child is at risk of harming themself.  2) If someone else is at risk of being harmed.  3) If children or elderly people are at risk of being neglected or abused.  4) If session files are subpoenaed by a Court order. *
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Parents / Guardian's understand the therapist will inform and include them if any serious health & safety issues become apparent. *
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PARENT / GUARDIAN AGREE: To honour, to the best of their ability, their child's confidentiality in regards to therapy sessions. *
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COUNSELLING VALUES:  Your child will be treated with respect and compassion, free from discrimination and exploitation, and will receive confidential service. Counsellors are required to maintain a professional relationship with clients (ie: counsellors can not be a friend, or family member). *
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COUNSELLING PROCESS: The Informed Consent document must be completed prior to receiving services. After this is completed, there is a process of engagement, such as reviewing personal and family history/experience, discussing issues of most concern, and potentially identifying goals, or areas of focus. The client is in control of the session, chooses the level of disclosure, can guide sessions according to their needs, and discontinue services when they choose. Individual sessions are approx. 50 minutes, and couples approx. 90 minutes. Clients will be provided options to a community resource if their need(s) are better suited for those resources. *
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BENEFITS AND RISKS OF COUNSELLING:  1) Counselling can influence life in positive ways, but 2) may also be emotionally painful. 3) Additionally, the process and results may create tension in existing relationships. 4) Not all counselling is effective. 5) If you feel your child is not making progress, please share your thoughts with your counsellor. *
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ONLINE COUNSELLING:  Online counselling uses a secure portal for face-to-face communication, nothing is recorded or stored. *
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FEE SCHEDULE: Individual counselling services are a flat fee of $120/session.  Couples counselling services are flat fee of $140/session.  Payments are to be made prior to your session.  *Please speak with your counsellor if there are financial constraints* *
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CANCELLATIONS:  Please provide your counsellor 24 hours notice of cancellation. *
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RECORD SESSION: Your counsellor may request permission from the client and the parent/guardian (you do not have to consent) to record a session to:  1) Provide feedback to the client.  2) To be viewed by a supervisor for training purposes. *
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COUNSELLOR QUALIFICATIONS:  Your counsellor is a licensed professional, overseen by a professional association, and guided by ethical Codes of Conduct. Access to these codes are available upon request. *
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CONSENT FOR CHILDREN: Please type the name of the child/ren you consent for counselling below: *
CUSTODY / GUARDIANSHIP: Please note, if there is a custody agreement in place more than one signature may be required. Please indicate below if it is Joint or Sole custody.       If there is a custody agreement, please provide the document during, or before, the first session with your child.   *
I have read, understand, and agree to the above information. *
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SIGNATURE AGREEMENT: By providing my e-mail, and typing my name below, I recognize this electronic signature will have the same force and effect as an original signature. *
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Last Name, First Name *
E-mail Address *
Phone Number *
Today’s  Date *
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