Corridor Christian Counseling Center, LLC
655 LIBERTY WAY, SUITE 6
P.O. BOX 667
NORTH LIBERTY, IA 52317
PH: (319) 665-2137
FAX: (319) 665-2134
E-MAIL: counseling@southslope.net
www.corridorchristiancounselingcenter.com
Therapists:
Esther Johnson, MS, LMFT, Owner
Kevin Krumvieda, PhD, Licensed Psychologist
Alyssa Drury, LMHC, CADC
Appendix A
Informed Consent for Treatment of Children and Adolescents
PARENT SEEKING THERAPY OR TESTING FOR MINOR CHILD(REN):
Only a legal parent or guardian can consent to the treatment of a minor child. Stepparents and foster
parents cannot consent to treatment, but may schedule the initial sessions.
Standard paperwork must be sent to the legal parent/guardian prior to the intake appointment. This
includes the following:
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Records Release Form
Child Social and Developmental History
Demographic Form
Notice of Privacy Practice
Office Policy Statement
Policy on Professional Fees
Legal Guardian Statement Form
Parents are asked to provide all contact information of the non-custodial parent so that paperwork can
be sent to them.
Both legal parents of the child must consent to the ongoing treatment of the minor child with CCCC.
If either parent requests that the therapy be discontinued, the therapist will inform the other parent of
this request and therapy will be discontinued immediately. This rescinding of treatment or of consent
must be in writing from the parent who is making this request.
The presenting parent assumes financial responsibility for all services rendered, even if the other parent
holds the insurance for the child(ren). The presenting parent is the individual who signs the office policy,
and therefore needs to take responsibility for the personal reimbursement with the other parent.
Regardless of arrangement, the present parent assumes all responsibility for payment of services, even
if the child(ren) arranges those appointments independently (e.g., teenager making own appointments
and then missing an appointment).
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If the non-custodial or other parent asks for information regarding the child in therapy, the therapist will
provide a summary of treatment, including presenting problem, dates of sessions, and general
treatment plan, as long as his/her parental rights are intact.
Foster parent seeking treatment for the child(ren)
Foster parents must bring to the initial appointment all required paperwork and consents signed by the
legal parent or DHS (if DHS has been granted limited guardianship for the purpose of medical,
educational, and mental health treatment). In some situations, the court might appoint the Guardian Ad
Litem for such purposes. Please check with your child’s DHS caseworker about who has legal
guardianship to sign the required paperwork.
Termination of parental rights
Foster/adoptive parents should bring a copy of the termination order to the appointment. If the
adoption has not been finalized, the appropriate DHS designee or whoever holds the temporary legal
guardianship of the child should sign the paperwork prior to the initial appointment.
Adoptive parent seeking treatment for the child(ren)
Adoptive parents need to bring the termination order and adoption order indicating the finalization of
the adoption and that legal guardianship falls with the adoptive parent.
Stepparents seeking treatment for the child(ren)
Stepparents cannot consent to the treatment of a stepchild. They cannot rescind consent for treatment
unless there is court documentation giving that stepparent limited guardianship for that specific
purpose. Stepparents would need to obtain proper consents from both legal parents as well as obtain a
release of information in order to seek treatment for the child.
Consent and Emergency Situations
For a child or adolescent who needs to be seen in an emergency or crisis situation, efforts will be made
by the therapist to obtain either oral or written consent from each parent. If such consent cannot be
obtained prior to the first appointment, the child or adolescent may be seen for a one-time
appointment to assist in the resolution of the crisis or referral for appropriate services.
INFORMATION FOR SEPARATED, DIVORCED, OR NEVER MARRIED PARENTS
Court Testimony
In some child custody proceedings, a judge may order my testimony if it is determined necessary. As
your child’s therapist, it is my ethical duty to provide your child with the best care possible. If I am asked
to provide records or testimony about treatment in court, this can contribute to a “dual-role”
relationship between your child and me. This means there are conflicting roles and can be damaging to
your child’s therapy experience due to violations of trust.
It is for these reasons, unless pre-arranged with me prior to initiating services, that I will not provide
therapy notes, test data, or testimony to the court as part of litigation. I will take necessary steps to
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quash any court order requesting such information or testimony. However, if after those efforts I am
required to provide test data, testimony, or records to the court (under court order), I reserve the right
to terminate services.
Custody and visitation issues
As your child’s therapist, I cannot make any recommendations about custody or visitation issues. If
these issues are a concern, your therapist may speak with you about a referral to another professional
for a formal custody evaluation, mediator, or guardian ad litem. It is assumed that both parents want to
work toward the best interest of their child, which includes maintaining a safe, therapeutic environment
for your child. The therapist will not provide records to attorneys or testify in court in a custody or
visitation dispute.
Court mandated therapy
Mandated therapy participation or therapy recommendations specifically related to treatment provided
by me should not be included in the divorce decree without my pervious consent.
Office behavior/conduct
At times, parents who are involved in divorce or custody disputes have difficulty maintaining
appropriate decorum in the waiting room, clinic office, and therapist office. Out of concern for your
child, other clients, and clinic staff, parents are asked to behave respectfully toward one another in the
office. If it is not possible to adhere to this expectation, parents may be asked to attend sessions
separately or services may be terminated.
By signing below, I am indicating that I have read, understand, and agree to the procedures of Corridor
Christian Counseling Center, LLC as it pertains to Informed Consent for the treatment of my child,
________________________________ (child’s name).
______________________________________
________________________
Legal Guardian Signature:
Date:
______________________________________
_________________________
Legal Guardian Signature:
Date:
______________________________________
_________________________
Clinician Signature:
Date:
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