Positive Perspectives, Inc.
Confidentiality & Policies Pertaining to Parents
We understand that this can be a stressful time, and sometimes parents disagree about parenting decisions for their
children. We want to honor both parents’ rights regarding medical/mental health decision-making for your child’s care
and create a relationship of support and trust with your family from the beginning of services. Therefore, in situations in
which parents are separated, divorcing, or divorced, we ask that both parents consent in writing to counseling services
for your child (or children) prior to meeting with them (in non-emergency situations). Please Note: While we ask that
both parents who are separated, divorcing, or divorced consent to treatment for their child(ren), we only require one
parent to consent to release of information to other medical, educational or personal sources.
We welcome therapy participation from all parents and relevant family members that are involved in parenting a
child. Ideally, we would like to meet with both parents together for the initial parent consultation. If that is not possible
we can meet with each parent separately (with your understanding that this will require two rather than one initial
interview sessions and resulting fees). If both parents are supportive of the child receiving mental health services, AND
we are able to consult with the alternate parent before your child’s session, we are happy to meet with one parent for
the initial session and mail/fax the alternate parent a copy of the policy and consent forms to review and sign prior to
our meeting with the child.
If there is a situation in which only one parent has custody and all rights to make medical/mental health decisions for
the child, then we ask that you bring us a copy of the most recent custody and decision-making agreement.
We have found that it is important for parents to clarify with each other who will be paying for which mental health
services, who will set up and cancel appointments, and who will communicate important information to us about your
child prior to initiating counseling services. If both parents plan to be involved with counseling and/or paying for the
session fees, we request that you both provide a secure credit card permission form that will enable us to easily collect
fees in a secure method.
Finally, we want parents to be aware that regardless of whether a parent has rights regarding medical/mental health
decisions, both parents typically have the right to therapeutic records for their child unless there is a court order
blocking their access to those records. If you wish to see your child’s records, we recommend that you review them in
the therapist’s presence so that you and he or she can discuss the contents. You are also entitled to receive a copy of
your child’s records or a summary can be prepared for you instead. Parents will be charged an appropriate fee for any
professional time spent in responding to information requests.
General Confidentiality Considerations
In general, the privacy of all communications between a client and a therapist is protected by law. Your child’s therapist
can only release information about your child to others with your written permission. But there are a few exceptions:
*
In some proceedings involving child custody and those in which your child’s emotional condition is an important
issue, a judge may order the therapist’s testimony.
Please continue on back 
Confidentiality & Policies Pertaining to Parents
Page |2
*
There are some situations in which we are legally obligated to take action to protect others from harm, even if
we have to reveal some information about a client’s treatment. For example, if a therapist believes that a child is being
abused, he or she must make a report to the appropriate state agency. Similarly, if your therapist believes that your child
is threatening serious bodily harm to someone else, protective actions are required. These actions may include notifying
the potential victim, contacting the police, or seeking hospitalization for the client. If your child threatens to harm
himself/herself, there may be an obligation to seek hospitalization or to contact family members or others who can help
provide protection.
*
You should also be aware that contracts with your health insurance company require that we provide
information regarding your child’s participation in treatment. We are required to provide a clinical diagnosis, and
sometimes we are required to provide treatment plans or summaries, or copies of the entire clinical record. In such
situations, we will make every effort to release only the minimum information about your child that is necessary for the
purpose requested. Though all insurance companies claim to keep such information confidential, we 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 bank. We will provide you with a copy of any report submitted, if you request it.
Name of Minor/Client: ___________________________________ Date of Birth: ________________________________
___________________________________
Print Name of Parent/Guardian
___________________________________
Print Name of Parent/Guardian
___________________________________
Print Name of Parent/Guardian
____________________________________________________
Parent/Guardian Signature
Date
____________________________________________________
Parent/Guardian Signature
Date
____________________________________________________
Parent/Guardian Signature
Date
Rev 1-15 CBL