Service Contract Signature Form

I have read and agree to the information stated in the service contract. I was able to ask any questions about the contract and was given a copy.

Summary of Service Contract:

• Authorization for Treatment
• The Process of Therapy
• Limits of Confidentiality
• Financial Responsibility
• No show fees: 1 free no show then $50 there after
• Court Fees

I herby authorize my child to attend counseling at The Kid’s Therapy Center LLC. I understand for the benefits of counseling to properly help my child may attend therapy without me in the room. At times I may be asked to attend therapy with my child.

Although I understand I have the rights of my child’s mental health file my therapist may not disclose information to me that is not in the best interest of the child. The ultimate goal of mental health therapy is to help my child. At no time will I use therapy in a way that is not in the best interest of my child such as in a legal proceeding for custody, unless it is suggested by my therapist.

If my child is 14 years or older I understand the ND Century Code: 14-10-17. (Minors-Treatment for sexually transmitted disease-Drug abuse-Alcoholism) does not need permission, authority, or consent of a guardian for treatment.

Notice of Privacy Practices Acknowledgement

I acknowledge that I have received a copy of The Kid's Therapy Center LLC Notice of Privacy Practices effective April 14, 2003.