I hereby give permission for my minor child to be interviewed for purposes of assessment as well as treated for individual therapy. Limits of Privacy when treating individuals under 18 are listed below: (All references to parents include legal guardian in absence of parent) • The therapist will maintain a record that contains dates of evaluation, therapy and treatment, goals, diagnoses and recommendations. • The parents of a client under the age of 18, have the right to read their child’s record, which includes information generated by the therapist. • The therapist will inform parents if the child is in immediate danger to self or others. • The therapist will communicate to the parent a summary of evaluation as needed or requested. • The therapist requests that parents respect their child’s privacy during assessment and therapy treatment. • The therapist can refuse to give information to the parents about their child, if the therapist predicts that disclosing such information could be harmful to the child.
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