Treatment of Minors. If you are under eighteen years of age, please be aware that the law does provide your parents with the right to examine your treatment records. It is my policy to request an agreement from parents limiting access to your records. If they agree, I will provide them only with general information on how your treatment is proceeding unless I feel that you are in some danger, in which case your parents will be notified of the concern. I will also provide them with a summary of your treatment when it is complete upon their request. Before giving them any information, I will discuss the matter with you and will try to resolve any objections you may have about what is to be disclosed. I graduated from the University of Phoenix with a Master of Counseling degree in 1995. I am a Licensed Professional Counselor in the State of Arizona, #LPC-2307. I am a Board Certified Neurotherapist. I have worked with adults, children, youth and families since 1986 in church, school, outpatient clinical, inpatient psychiatric and community development settings. CONTACTING YOUR COUNSELOR To schedule or change appointments, you can use my online service from my website, xxx.xxxxxxxxxxx.xxx. If you are uncomfortable using the online service or if you want to speak with me directly for any other reason, you can call me at 000-000-0000. If I am unavailable, please leave a message and I will return your call as soon as possible. If you feel that you cannot wait for a returned call, you should call 9-1-1 or one of the crisis numbers listed below. If I am unavailable for an extended period of time, I will provide you with the name of a trusted colleague you can contact if necessary. CRISIS NUMBERS 911 Medical / life threatening emergency Behavioral Health Crisis Line 000-000-0000 000-000-0000 Domestic Violence Hotline Suicide Crisis Hotline 000-000-0000 000-000-0000 Child Abuse Hotline Not sure who to call: Community Information and Referral 000-000-0000 Xxxxx Xxxxxx, M.C., N.C.C., L.P.C., B.C.N 000 X. Xxxxx Xxxxxx, Xxxxx X Xxxxxxxxxx Xxxx, XX 00000 623-330-3197 xxxxx@xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx CLIENT’S RIGHTS
Treatment of Minors. We believe in providing a minor child with a private environment in which to disclose himself or herself in order to facilitate therapy. Therefore, it is important for guardians to give permission for therapists to use our professional discretion, in accordance with professional ethical standards and local, state and federal regulations, in deciding what information revealed by your child is to be shared with guardians. Regular parent consultation occurs via telephone or face-to-face conferences in which feedback is provided and specific recommendations are offered. Confidentiality for child/adolescent clients is maintained in order to enhance and promote open and honest disclosure and a therapeutic relationship with the exception of unsafe or risky behaviors warranting further intervention with parent involvement. ( )
Treatment of Minors. Persons under the age of 18 must have permission of the parent or legal guardian to receive therapeutic services. Parents will be involved in treatment as I deem necessary while maintaining the confidentiality of the client except in cases of dangerous drug use, suicidal ideation or running away. In cases of divorce, I will want to involve both parents unless rights have been severed for one or it is otherwise not feasible to do so. I will not serve as a witness in custody disputes or provide records for such matters. I ask you to agree to accept this policy. If you go to court you will need to receive an evaluation from another professional for those involved. I will provide a summary, if necessary, but not actual records to the court. Charge for this service will be $80 per hour of preparation must be paid in advance. If required to attend court proceedings the fee will be $80 per hour with one hour payable in advance. The charge can be avoided if cancellation is made one week in advance.
Treatment of Minors. If you are consenting to the treatment of a minor child, you will be required to provide a copy of the most recent Court Order Custody Agreement and/or Parenting Plan, if applicable, that gives you the authority to consent to the treatment of the child. By signing this form, you agree to keep me informed of any supplemental court orders or other proceedings that impact your parental rights, custody arrangements, or decision-making authority. Failure to produce the Court Order will prohibit me from seeing the minor child. If there is joint medical decision-making authority for your child, I will require both parents to consent to treatment and will not proceed until such consent is obtained. In the course of treatment with your child, I may involve other family members in your child’s treatment. However, please remember that my client is your child, not the other family members of the child. Any meetings with you or other family members will be documented in your child’s record. These notes will be available to anyone who has legal access to your child’s treatment record. Therapy is most effective when there is a trusting relationship between the therapist and client. Privacy is important in establishing trust, and as a result, it is often important for child or adolescent clients to have a level of privacy around the therapy. It is my policy to provide parents with general information about their child’s treatment, but not to share specific information disclosed during therapy. This includes behaviors that you may not approve of but which do not place your child at imminent risk or danger. If I ever feel that your child is in danger, I will communicate this information to you. If you have questions about the types of information I will share, you can feel free to ask me hypothetical questions about situations that I would or would not disclose to you.
Treatment of Minors. We realize that many families are in a state of change. Divorced, separated, single parents and blended families are common. In many of these families, the question of who is financially responsible for the child's care can be complicated. The policy in this office is that the parent who requests treatment for/accompanies the minor is responsible for all fees incurred. If another person is responsible for paying the bill, it is the responsibility of the adult who requests treatment for/accompanies the minor to forward the bill to that individual. If that individual does not pay, both parties will be referred to a professional collection agency.
Treatment of Minors. Treatment of patients under the age of 18 will be provided only with the consent of the parent or legal guardian. In cases of divorce, a copy of the custody agreement must be provided. Most custody decrees entitle the non-custodial parent to access the health record without consent from the custodial parent. By signing the consent form on page 3 of this document, client acknowledges that he or she is the guardian (as established by the state or the divorce decree) of any minor presented for treatment. Patients under 18 years of age (who are not emancipated) and their parents should be aware that the law may allow parents to examine their child’s treatment records. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. If the patient is a minor, he/she will not be seen without his/her legal guardian present or a signed letter from the legal guardian permitting another adult to attend the appointment with the minor patient. Medication and Refill Policy: We require that patients on psychiatric medication be seen at least once every 4 months. If a patient has not been seen in the office in the last 4 months, a follow-up appointment will be required prior to another refill being issued. Medication prescriptions will be submitted electronically. By choosing to become a patient at Xxxxxxxx X. Xxxxx, MD, P.A., you are consenting to having prescriptions submitted electronically to your preferred pharmacy. Also, you are authorizing our providers to retrieve prescription history via SureScripts clearing house. Refills can be submitted by calling the office and following the prompts to leave a message, by secure message via the online portal, or through your pharmacy. It is recommended that refills be called in 7-10 days in advance, but must be requested at least 5 business days in advance of the date they are needed. It is your responsibility to contact the office before you run out of medications. Refill requests for stimulant medications (Ritalin, Adderall, Vyvanse, Metadate, Concerta, etc.) need to be made directly to our office (not the pharmacy). Stimulant refill requests can be called in during our office hours or after hours, by following the message prompts. Stimulant prescriptions expire 21 days from the date they are written. If your prescription expires before you take it to the pharmacy, you will need to contact the office to request a new prescription. There...
Treatment of Minors. Clients under the age of 18 must have the permission of a parent/legal guardian to receive counseling or psychological services. The psychologist will involve parents in treatment as deemed appropriate. While parents have the right to access their child’s file, confidentiality between the psychologist and minor is strongly encouraged. When counseling teenagers, they are made aware when their parents have called the psychologist to discuss their case and the general nature of the discussion. Issues of safety of which a psychologist is aware will be discussed with a parent. Issues of safety include but are not limited to engaging in dangerous behavior such as the use of illicit drugs or the use of inappropriate medications, suicidal thoughts or plans, and running away. If you have a question concerning what constitutes a safety concern for a particular child, please discuss this with your psychologist. Cancellation Policy Client’s session times are reserved exclusively for them. I require 24 hours notice in order to cancel or reschedule an appointment. Failure to do so will result in full session fee charged for the missed appointment. Appointments scheduled on Monday need to be cancelled by 12:00 p.m. on the previous Friday in order to prevent being charged. This charge must to be paid before or at the time of your next appointment. Reminder calls are not made prior to the scheduled appointment. Exceptions are made for sudden illness, emergencies and severe inclement weather. Thank you for your consideration regarding this important matter.
