Deborah L. Conley, LCSW
825 W. State Street, Suite 117E
Geneva, IL 60134
Phone: (847) 261-2911
Child and Adolescent Service Agreement
Prior to beginning treatment, it is important for you to understand my approach to therapy with minors and your child’s confidentiality during the course of his/her treatment. The information herein is in addition to the information contained in the Patient-Therapist Agreement. Under HIPPA, I am legally and ethically responsible to provide you with the informed consent.
One risk of child therapy involves disagreement among parents and/or disagreement between parents and therapists regarding the best interest of the child. If such disagreements occur, I will strive to listen carefully so that I can understand your perspectives and fully explain my perspective. We can resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress. Untimely, you will decide whether therapy will continue. If you decide that therapy should end, I will honor that decision. However, I ask that you allow me the option of having a few closed sessions to appropriately end the treatment relationship.
Therapy is most effective when a trusting relationship exists between the therapist and client. Privacy is especially important in securing and maintaining that trust. One goal of the treatment is to promote a stronger and better relationship between children and their parents. However, it is often necessary for children to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for tweens and adolescents who are naturally developing a greater sense of independence and autonomy.
In my practice, I frequently provide services to children whose families are experiencing or have experienced divorce or separation. Sometimes those families are also involved in disputes over custody and parenting.
When serving a child in an unresolved or contentious custody situation, I feel strongly that both parents must give written consent for the child(ren) to participate in therapy. The only exceptions would be if a parent is unavailable to give consent (for example, his/her whereabouts are unknown), if the named parent has not been legally adjudicated the parent of the child, or if one parent has been given sole custody of the child(ren). That parent must have specific authority to provide written and informed consent to psychotherapy. If a parent has restricted access to their child(ren) due to domestic abuse or child protection concerns, I would like to be provided a copy of the court order prohibiting contact with the child(ren), or written orders from DCFS. In this
Deborah L. Conley, LCSW
825 W. State Street, Suite 117E
Geneva, IL 60134
Phone: (847) 261-2911
Circumstance, the parent who is restricted from contact with the child (ren) may not be asked to provide consent therapy.
Part of my role as a therapist is to help children understand and cope with the major transitions, adjustment reactions, and loss that may accompany divorce or separation. I provide a safe, neutral relationship and environment in which the child is not torn by allegiances and can express honest feelings. In order for this to occur, a child must see me as working on their behalf and not an agent of either parent.
I do not conduct parenting evaluations, custody studies or mediation to determine parenting time (i.e. visitation schedules). The courts have professionals who fulfill these roles. In addition, if parents in a conflictions legal relationship try to involve me in an attempt to prove a case against each other it can be extraordinarily damaging to the child who has come to trust our work as safe, “not taking sides” , and confidential.
It is my policy to provide you with general information about treatment status. If it is necessary to refer your child to another mental health professional with more specialized skills, I will share that information with you. I will not share with you what your child has disclosed to me without your child’s consent. At the end of treatment, we will meet to discuss goals that were met, and areas that may need future intervention.
Summary of Agreement
- If you decide to terminate treatment, I have the option of having a few closing sessions with your child to properly end the treatment relationship.
- At the end of treatment, I will meet with you to provide a general description of goals, progress made, and potential areas that may require intervention in the future.
- If necessary to protect the life of your child or another person, I have the option of disclosing information to you without your child’s consent.
- You agree that my role is limited to providing treatment and that you will not involve me in any legal dispute, especially a dispute concerning custody or visitation arrangements.
- If there is a court appointed evaluator, and if appropriate releases are signed and a court order is provided, I will provide general information about the child which will not include recommendations concerning custody or visitation arrangements.
My signature below indicates I understand and agree to abide by the above conditions. By signing, I am also confirming that I have the legal standing (guardianship, right to make medical care decisions) to consent to the minor child’s mental health treatment.
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Parent/Guardian SignatureDate
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Witness Date