Common Contracts
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Therapy Services Agreement for Child/AdolescentNovember 13th, 2021
Client Information Child/Adolescent’s Name: Date of Birth (yyyy-mon-dd): Full Address: Parent/Guardian Name(s): Relationship: Parent/Guardian(s) Phone Number: Is it okay to leave a message? Parent/Guardian(s) E-mail: Is it okay to communicate through e-mail? (please note, confidentiality cannot be guaranteed via e- mail) Confidentiality All communication regarding treatment and all records relating to the provision of therapy services are confidential and will not be disclosed without written consent. Confidentiality cannot be guaranteed over e- mail communication. The law does however; place limits on confidentiality related to specific disclosures.These include:1. Risk of imminent danger to self or others2. Abuse of child or a vulnerable adult3. Court ordersWorking with a child includes the difficult task of protecting the child’s right to privacy while at the same time respecting the parent/guardian’s desire for information. Therapy is most effective when
