I, (names of parent/legal guardian)_________________________________________, hereby agree to my child/client(name) ______________________________________, beginning service with Jennifer Moore, LCSW (referred to at times in this document as “my child’s social worker).
I have read her DECLARATION OF POLICIES AND PROCEDURES. I have discussed with my child’s social worker the operating policies and procedures of this practice setting, the role and responsibilities of my child’s social worker, and my roles and responsibilities as parent/guardian. I understand that I am consenting to begin my child’s treatment, not my own, and that although my consent is important and necessary, my role is to help provide information, to plan, to assist in measuring progress, and to coordinate my child’s treatment. I understand my rights to receive and refuse services, to privacy and confidentiality, to respectful treatment, to be informed about my child’s treatment, to have reasonable access to the clinical record and amend it if I find errors, and to file a complaint if I believe I have been unfairly or unethically or disrespectfully treated. I have asked all questions that have occurred to me.
I understand the purposes of this setting, the service approaches and methods used, and the qualifications of my child’s social worker.
I understand that after my child is assessed, we will develop a service plan and that I will make another agreement to follow through with the service plan. As part of a complete assessment, I understand that I may be asked to have my child have a physical examination with his or her pediatrician and to request that his or her reports be sent to Jennifer Moore, LCSW.
I understand my financial responsibilities and arrangements with my insurance payer or payers, the rules about notifying the social worker if my child has to miss an appointment or will be late, the charges for broken appointments and late arrivals without prior notification, and the consequences if my account is past due. I understand that sessions I request with my child’s social worker or that he or she requests with me will be charged at the same hourly fee as our child’s service.
I understand what to do if my child has a life threatening emergency (I should call 911 for emergency assistance). I should call my child’s social worker after emergency assistance has been obtained.
I understand that my child’s social worker will protect my privacy and that confidential information about me will be revealed only if I give my written consent, if my child’s safety or the safety of someone else is threatened, or if a court orders the information released.
I also understand that my child’s social worker will keep discussions he or she has with me in the absence of my child confidential and will keep material discussed with my child in my absence confidential. However, I understand that the social worker may breach confidentiality with my child if my child talks about harming himself or herself or someone else. I understand that Jennifer Moore, LCSW is a mandated reporter of suspected abuse. If abuse is suspected, confidential information will be breached and reported to appropriate authorities. We will be encouraged, as a family, to talk about our respective sessions with the social worker. However, my child’s social worker will not transmit information from one of us to the other(s).
In granting consent for the release of confidential information about my child from one professional to another or to my health plan, I stipulate that
____ I wish to sign my own release of information, and I reserve the right to withhold permission to release part or all of the information sought; or
____ I grant permission to Jennifer Moore, LCSW the right to release confidential information about my child to________________________.
I understand that my written consent will be obtained if information about my child is to be used for research or training purposes or if my child’s social worker wishes to audiotape or videotape the sessions for any reason.
I understand that my and my child’s relationship with the social worker is now and will be in the future solely a professional relationship and that I will have no shared interests or activities outside of my child’s treatment.
I realize that, although service is recommended for my child and will probably be helpful, there are no guarantees that any or all of his or her problems will be remedied. I further understand that service involves possible risks as well as benefits. Hence, I and my child may experience stress, strained relationships, or other difficulties as a result of the service process.
Finally, I understand that service will terminate when the goals of the service plan have been fulfilled. However, I also understand that I may end service at any time I wish or feel that I and/or my child need to do so. I further understand that my child’s social worker may also end service if my child does not make progress, has needs that the social worker cannot meet, or if I and/or my insurer are no longer able to pay for services. If my child’s service is ended before the goals of the service plan have been accomplished, I understand that the social worker will do all possible to refer my child to an alternative source of care.
__________________________________
Legal Guardian Signature/Date
__________________________________
Jennifer Moore, LCSW /Date