Child & Adolescent Therapy Consent Form

PLEASE READ THIS DOCUMENT CAREFULLY FOR ALL TERMS AND CONDITIONS. IT IS A LENGTHY DOCUMENT, BUT CONTAINS CRUCIAL INFORMATION REGARDING THE THERAPEUTIC PROCESS. 

Karin Gerber is an educational psychologist registered at the Health Professions Council of South Africa (HPCSA). She has a BEdPsych (Educational Psychology) degree, as well as an MEdPsych (Educational Psychology) degree. Karin is trained in play therapy interventions, as well as Jungian Sandplay therapy and Brain Working Recursive Therapy (BWRT). Her experience includes play therapy, individual psychotherapy, and parent guidance.

Thank you for trusting me to assist you with your concerns. Please take the time to read and understand this document and ask me about any section which may be unclear to you.

I, Karin Gerber, will provide psychotherapeutic services to your child. The goal is to help your child be successful emotionally, socially and academically. Parent guidance sessions are available to enhance your child’s success. I am requesting your involvement and need permission to see your child.

This consent is valid until termination of the therapeutic relationship. You have the right to revoke consent at any time. Verbal or written notification will be accepted. Please read this agreement carefully, and sign if you fully AGREE & UNDERSTAND these terms & conditions.

In order to authorise mental health treatment for your child (under the age of 18 years), you must have either sole or joint legal custody of your child. If you are separated or divorced from the other parent of your child, please notify me immediately. I will ask you to provide me with a copy of the most recent custody decree that establishes custody rights of you and the other parent or otherwise demonstrates that you have the right to authorise treatment for your child. If you are separated or divorced from the child’s other parent, please be aware that it is my policy to notify the other parent that I am meeting with your child. I believe it is important that all parents have the right to know, unless there are truly exceptional circumstances, that their child is receiving mental health evaluation or treatment. It is also my policy that the parent who initiates therapy shall be responsible for payment of the child's consultations. 

One risk of child therapy involves disagreement among parents and/or disagreement between parents and the therapist regarding the child’s treatment. 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. Ultimately, parents decide whether therapy will continue. If either parent decides that therapy should end, I will honour that decision, unless there are extraordinary circumstances. However, in most cases, I will ask that you allow me the option of having a closing session with your child to appropriately end the treatment relationship.

THERAPY

The therapeutic process usually begins with a parent consultation first, where your concerns regarding your child’s social-emotional functioning can be discussed. It provides a platform for me to understand how the problem has been or is affecting your lives, and what has been effective in addressing this in the past. From here, we will schedule a weekly timeslot for your child’s therapy appointments. I require a minimum of 3 sessions before I will be able to meet with you again to provide feedback. I prefer not to provide feedback via email or telephonically, as an in-person conversation provides the best platform to provide context in terms of the child’s progress, and the opportunity then exists for us to share our knowledge about the child with each other. After your child's 3rd therapy session, it is your responsibility to schedule the parent feedback consultation.  

Therapy has both benefits and risks. Risks may include the child experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, amongst others, because the process of therapy often requires discussing unpleasant aspects of the child’s life. 

However, therapy has been shown to have benefits for individuals and families. Therapy often leads to significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions of specific problems. There are no guarantees regarding the outcome of psychotherapy, and there are no “quick fixes / solutions”. The need for therapy stems from a history of difficulties, and it cannot be addressed overnight. I therefore urge you to be realistic in your expectations of your child’s therapy. Some children show drastic improvement after a few sessions, while others may take longer. In other instances, the benefits of therapy may only manifest as children grow older, and can apply skills they have internalised from therapy. Therapy is a process, and it requires each party involved in the process (child, parents / guardians and psychologist) to be on board and an active member of the therapeutic team. To be most successful, you will have to work on things outside of sessions, in accordance with the direction given in the parent feedback sessions. 

INDIVIDUAL PARENT / GUARDIAN COMMUNUCATIONS WITH ME

In the course of my treatment of your child, I may meet with parents/guardians either separately or together. Please be aware, however, that, at all times, my client is your child – not the parents/guardians nor any siblings or other family members of the child.

If I meet with you or other family members in the course of your child’s treatment, I will make notes of that meeting in your child’s treatment records. Please be aware that those notes will be available to any person or entity that has legal access to your child’s treatment record.

MANDATORY DISCLOSURES OF TREATMENT INFORMATION

In some situations, I am required by law or by the guidelines of my profession to disclose information, whether or not I have your or your child’s permission. I have listed some of these situations below. Confidentiality cannot be maintained when:

  • Child clients tell me they plan to cause serious harm or death to themselves, and I believe they have the intent and ability to carry out this threat in the very near future. I must take steps to inform a parent or guardian or others of what the child has told me and how serious I believe this threat to be and to try to prevent the occurrence of such harm.
  • Child clients tell me they plan to cause serious harm or death to someone else, and I believe they have the intent and ability to carry out this threat in the very near future. In this situation, I must inform a parent or guardian or others, and I may be required to inform the person who is the target of the threatened harm [and the police].
  • Child clients are doing things that could cause serious harm to them or someone else, even if they do not intend to harm themselves or another person. In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed.
  • Child clients tell me, or I otherwise learn that, it appears that a child is being neglected or abused--physically, sexually or emotionally--or that it appears that they have been neglected or abused in the past. In this situation, I am [may be] required by law to report the alleged abuse to the appropriate state child-protective agency.
  • I am ordered by a court to disclose information.

DISCLOSURE OF MINOR’S TREATMENT INFORMATION TO PARENTS

Therapy is most effective when a trusting relationship exists between the psychologist and the client. Privacy is especially important in earning and keeping that trust. As a result, it is important for children to have a “zone of privacy” where children feel free to discuss personal matters without fear that their thoughts and feelings will be immediately communicated to their parents. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy. It is my policy to provide you with general information about your child’s treatment, but NOT to share specific information your child has disclosed to me without your child’s agreement. This includes activities and behaviour that you would not approve of — or might be upset by — but that do not put your child at risk of serious and immediate harm. However, if your child’s risk-taking behaviour becomes more serious, then I will need to use my professional judgment to decide whether your child is in serious and immediate danger of harm. If I feel that your child is in such danger, I will communicate this information to you.

If your child tells me, or if I believe based on things I learn about your child, that your child is addicted to drugs or alcohol, I will not keep that information confidential. Even when we have agreed to keep your child’s treatment information confidential from you, I may believe that it is important for you to know about a particular situation that is going on in your child’s life. In these situations, I will encourage your child to tell you, and I will help your child find the best way to do so. Also, when meeting with you, I may sometimes describe your child’s problems in general terms, without using specifics, in order to help you know how to be more helpful to your child.

DISCLOSURE OF MINOR’S TREATMENT RECORDS TO PARENTS

Although the laws of our country may give parents the right to see any written records, with regard to your child’s treatment, by signing this agreement, you are agreeing that your child or teen should have a “zone of privacy” in their meetings with me, and you agree not to request access to your child’s written treatment records.

PARENT/GUARDIAN AGREEMENT NOT TO USE MINOR’S THERAPY INFORMATION/RECORDS IN CUSTODY LITIGATION

When a family is in conflict, particularly conflict due to parental separation or divorce, it is very difficult for everyone, particularly for children. Although my responsibility to your child may require my helping to address conflicts between the child’s parents, my role will be strictly limited to providing treatment to your child. You agree that in any child custody/visitation proceedings, neither of you will seek to subpoena my records or ask me to testify in court, whether in person or by affidavit, or to provide letters or documentation expressing my opinion about parental fitness or custody/visitation arrangements.

Please note that your agreement may not prevent a judge from requiring my testimony, even though I will not do so unless legally compelled. If I am required to testify, I am ethically bound not to give my opinion about either parent’s custody, visitation suitability, or fitness. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, I will provide information as needed, if appropriate releases are signed or a court order is provided, but I will not make any recommendation about the final decision(s). 

Furthermore, if I am required to appear as a witness or to otherwise perform work related to any legal matter, the party responsible for my participation agrees to reimburse me at my current consultation rate per hour for time spent traveling, speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, and any other case-related costs.

APPOINTMENTS

Scheduled sessions begin at the appointed time and lasts exactly 50 minutes. For children younger than 12 sessions last 45 minutes, to allow time for preparing the play room for the next client. Sessions are usually once a week, at a time we agree upon, although depending on your request and your child’s needs, some sessions may be more or less frequent. The time scheduled for your child’s appointment is assigned to him/her alone. You are responsible for arriving on time. If you are late, the appointment will still end at the scheduled time. Please could you arrive and leave on time, as I am unable to provide supervision for a waiting child. Please note that children under the age of 10 cannot be left unattended in the waiting area.

You accept responsibility that appointments are taken as confirmed at the time of the scheduled booking. Any reminders from Karin Gerber serve as a courtesy & have no bearing on the confirmation of an appointment.

Any late-coming will shorten the session and the session will be charged in full. Sessions cannot run overtime if you are late as this will impact the client scheduled after you. Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 advance notice of cancellation [please see 24 hour cancellation policy]. If you or I believe that I am not the right therapist for your child, I will give you referrals to other trusted practitioners whom I believe are suited to help you.

CANCELLATION OF APPOINTMENTS

A 24 hour cancellation policy applies. This 24 hour cancellation policy is standard in the medical and mental health fields and will be strictly enforced. The reason for this policy is that 24 hours’ notice is required as advance warning as it enables me the opportunity to schedule someone else for that time. This is important because others may be on a waiting list or may be looking for an opportunity to use that session slot.

If you miss a session without cancelling, you will be billed as such which will most likely not be covered by your medical aid. Thus, you are accepting responsibility that a missed session will be billed in full and may (depending on your medical aid) be for you own personal account. You also accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Karin Gerber serve as a courtesy & have no bearing on the confirmation of an appointment.

As much advance notice as possible is appreciated. 

LATE ARRIVAL POLICY

Please note that you need to notify me if you will be late for your appointment. Then your appointment will be held for you and you can use the remaining time within that 50 minute slot. If you do not notify me of your late arrival, I will wait 15 minutes, after which I will assume that you are not coming and may leave the office, especially if this is the last session slot of the day. In such a case, you will be charged in full for a missed appointment.

PROFESSIONAL FEES

Fees are payable directly after each consultation. You will receive a statement reflecting your payment, which you can submit to your medical aid for reimbursement. 

If we meet for more than the usual allocated 50 minute time, I will charge accordingly. In addition to weekly appointments, I charge this same session rate for other professional services you may need for your child, though I will prorate the hourly cost if I work for periods of less than one hour.

Other professional services include: PMB applications/motivations, referral letters to other professionals such as doctors or psychiatrists, sick notes, telephonic conversations lasting longer than 10 minutes, attendance at meetings or telephonic consults with other professionals you have authorised, and the time spent performing any other service you may request of me.

Any sessions/consultations with third parties which are reasonably necessary as part of your child’s treatment will be charged to you, even if at the request of Karin Gerber. 

BILLING AND PAYMENTS

Consultations are payable directly after each appointment. You are welcome to settle your account by card, EFT or cash. You will receive a statement with an invoice number to use as payment reference for EFT payments. Please take note that if you choose to use personal information (such as name and surname) as a payment reference, that third parties will have access to this information. 

If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary, its costs and my billable time lost to this process will be included in the claim.] In most collection situations, the only information I will release regarding a patient’s treatment/assessment is his/her name, the dates, times, and nature of services provided, and the amount due.

If you are unable to pay for a session due to unforeseen financial constraints, please discuss this with me beforehand in order to make an arrangement. Please note that it is my right to employ a Debt Collector if you do not pay for my professional services provided to you. 

The practice withholds the right to terminate non-emergency treatment due to non-payment of accounts.

I am under no obligation to draw up written reports of any nature relating to therapeutic services offered. Should I undertake to draw up a written report, upon request to do so by you, the time spent drawing up the report will be charged for at the current private rate per hour. 

I provide a confidential therapeutic service, and not a psycho-legal or forensic service. However, should it be deemed necessary by a court of law for me to draw up a psycho-legal or forensic report of any nature whatsoever, or to appear in court for any reason related to any services offered, the time utilised for these purposes will be charged for at the current private rate per hour. Please note that this charge is not covered by any medical scheme. It will therefore be your responsibility to make full payment for such services beforehand, even if another party compels me to testify via a court of law. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality.  

As the undersigned, you are accepting full responsibility for my account & to settle any outstanding payments.

Please note that fees are subject to annual increase.

VERY IMPORTANT: MEDICAL AID REIMBURSEMENT AND PRESCRIBED MINIMUM BENEFITS

In order for us to set realistic treatment goals and priorities for your child, it is important to evaluate what resources you have available to pay for treatment. If you have a medical aid policy, it will usually provide some coverage for mental health treatment, usually making use of your medical aid savings. I will fill out forms and provide you with whatever assistance I can in helping your child receive the benefits to which he/she are entitled; however, you (not your medical aid company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your medical aid policy covers.

You should carefully read the section in your medical aid coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your medical aid company. Due to the rising costs of health care, medical aid benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available.

Prescribed Minimum Benefits (PMB) plans often require authorisation before they provide reimbursement for mental health services. Please note, if you make use of a PMB, you are swapping inpatient care for outpatient therapy. Thus, you may forfeit in-hospital care for your child if you utilise PMB services for outpatient sessions. PMBs are only available for certain ICD-10 diagnostic codes. It is also very important to note that having an approved PMB condition is seen as a pre-existing mental health condition which might cause certain limitations in your child’s future in terms of applying for life cover or moving abroad. You will have to weigh up the pro’s and cons of utilising PMB sessions versus the potential future limitations for your child. 

Also take note that PMB plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. Though a lot can be accomplished in short-term therapy, sometimes parents/guardians or the child client feel that they need more services after medical aid benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, you will have the option available to you to pay cash for the sessions.

You should also be aware that most medical aid companies require that I provide them with your child’s clinical diagnosis. Sometimes I have to provide additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire record (in rare cases). This information will become part of the medical aid company files. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any records I submit, if you request it. You understand that, by using your medical aid, you authorise me to release such information to your medical aid company. I will try to keep that information limited to the minimum necessary.

Once we have all of the information about your medical aid coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by the medical aid contract].

COMMUNICATION

I am not always able to answer calls or emails during the day, as I am in consultation with clients. Emails are seen as lower in priority and it may take up to 5 working days to receive a reply. If your query requires clinical / professional input, it is best to rather schedule an appointment (either face to face, telephonically or online). Effective and ethical guidance cannot be provided via email. These consultations will be billed accordingly. 

Please note that I do not befriend anyone on any social media networking sites (such as Facebook or Instagram) who is or has been a client of mine.

You are welcome, though, to follow my professional Facebook and Instagram pages @karingerberedpsych. 

In emergencies, if you are unable to reach me and feel that you cannot wait for me to return your call, contact your general physician (GP) or the nearest emergency room and ask for the psychologist or psychiatrist on call. Alternatively you can contact:

  • South African Depression and Anxiety Group (SADAG): 011 234 4837
  • Akeso Psychiatric response unit (24 hours): 0861 435787
  • Suicide Crisis Line: 0800 567567

If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

INDEMNITY

Whilst engaging in Psychotherapy sessions at Amatoni III, Unit 52, 23 Herold Street,, Stellenbosch, I the client, accept full responsibility for my safety on the premises. I, the client, fully indemnify the therapist, Karin Gerber, the landlord, the staff, and any other persons associated with this property. I, the client, indemnify the above mentioned persons, including, but not limited to: any injury, damage, loss, or death resulting from any cause whatsoever. In the case of minors, this indemnity is accepted, understood and signed by the legal guardian. Any person/s that accompany the client to the premises is also the full responsibility of the undersigned client. The cost associated of replacing, or repairing damage to any part of the property, however caused by any of the above mentioned, shall be paid for by the undersigned. Any medical conditions or allergies must be communicated by the client to the psychologist.

OTHER RIGHTS

If you are unhappy with any aspect of your child’s therapy, I encourage you to talk to me about it. Such comments will be taken seriously and handled with care and respect. You may also request that I refer your child to another therapist, and you are free to end your child’s therapy at any time. It is imperative that you inform me if you consult any other psychologist regarding your child while he / she is still in therapy with me. 

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