CONSENT FOR MINORS OVER AGE 12 AND UNDER AGE 18
To be read separately by minors ages 12-18 and their parents. For kids under the age of 12, parents may choose to read this form out loud and/or sign on their behalf.
Hello. I look forward to getting to know you! My name is Monica Huston and I am a Marriage and Family Therapist. I help people with their personal problems so they can live a happier life.
If I become your therapist, we may see each other for one hour each week in my office to talk about how we can make your problems go away. Once you’re feeling better, we will say goodbye and stop seeing each other. If your parents say its okay, you can always come back if you want to!
Before we meet, I want you to know that everything we talk about in my office is private. I do not tell your parents what you say. That means you can tell me your secrets and your parent’s feelings won’t get hurt. However, there are 3 times when I might have to break this rule. I wrote them down here:
If you are hurting yourself or another person
If the law says I have to
If you give me permission
If these things don’t happen, then your secrets are safe with me! Your parents are reading this form too and they already know that these are the rules of therapy.
CONFIDENTIALITY WITH YOUR PARENTS
Every now and then, I will talk to your parents to tell them how you’re doing. For example, I tell them you are showing signs of improvement, learning new ideas and figuring out how to solve problems. I also share with them cool parenting tips they can try with you. If they ask for a written report, I will write one. Still, I do not tell them exactly what you tell me unless the three things I wrote above happen.
Last point! When I do think it is important for your parents to know something you said, sometimes I will recommend that we invite them to therapy. There are times when our parents can be the best ones to help us and we need to give them a chance to make things better. If this happens, I give you plenty of warning and I let you do the talking unless you need my help.
Congratulations! You made it to the end. In summary, therapy is a place to get help with your problems so you can live a happier life. Once you trust that I will keep your secrets safe, then I can learn about you and figure out how to help your life improve.
If you have any questions, please ask me the next time you see me. If you’re ready to get started with therapy, let's begin!
INFORMED CONSENT FOR COUPLES AND FAMILY THERAPY
If you are reading this form, then you are considering therapy where the treatment unit consists of one or more individuals.
MY “NO SECRETS” POLICY
This written policy is intended to inform you, the participants in couples or family therapy, that when I work with a couple or family, I consider all members within the couple or family “the patient” or treatment unit. Therefore, when we meet as a couple or family, I practice full disclosure with all members of the treatment unit. I do not keep secrets.
If there is a request for the treatment records of the couple or family, I will seek authorization of all members of the treatment unit before I release confidential information to third parties. If my records are subpoenaed, I will assert the therapist-patient privilege on behalf of all parties within the treatment unit.
During the course of my work with a couple or family, I may see smaller parts of the treatment unit (i.e. one partner or two siblings) for one or more sessions. These sessions should be seen as a part of the work I am doing with the whole family or couple unless otherwise indicated. Individual sessions within couples or family therapy are considered confidential except under two circumstances.
When affairs, addictions and abuse are discovered. I do not participate in withholding information of this nature from the treatment unit. If abuse is presently occurring among the members of the treatment unit, therapy may be terminated to protect the wellbeing of all members of the treatment unit.
If I am to effectively serve the unit being treated, I may use my best judgment as to whether, when, and to what extent I may request additional disclosures to the treatment unit and will also, if appropriate, first give the individual, or smaller part of the treatment unit being seen, the opportunity to make the disclosure. I will give you 30 days to disclose the secret and after that time period, I will need to terminate therapy if it has not happened. If you feel it necessary to talk about matters that you do not want disclosed, you might want to consult with an individual therapist who can treat you individually.
This “No secrets” policy is intended to allow me to continue to treat the patient (the couple or family unit) by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated.
Every member of the treatment unit may expect full disclosure of the therapy process during couples or family therapy. Abuse, affairs and addictions revealed within individual sessions are considered necessary disclosures among some others on a case by case basis.
For any additional questions, please email me directly.