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Information & Registration |
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MY HEALING PLACE CONSENT FOR SERVICES – CHILD CLIENT
I, ______________________________, hereby give full consent for my child, _____________________to receive the services of My Healing Place until I give notification of any changes or until My Healing Place determines that services are no longer necessary, I certify that I have legal responsibility for this child and am authorized to seek treatment for him/her. I understand that if any court reports, court appearances or court consultations are required in association with treatment at My Healing Place, I will be responsible for payment in advance at full fee for these services. I agree to give My Healing Place advance notice of such services.
In addition, I understand that as a client of My Healing Place my child and I have the following rights and responsibilities in the therapeutic setting: · To be treated with dignity and respect. · To appropriate treatment in the least restrictive setting available consistent with the protection of myself and others · To give input for my own treatment plans. · To an explanation of the benefits, effects, alternatives and risks of all treatment. · To refuse treatment and receive and explanation of possible consequences of refusing, unless the court orders such. · To meet with the person treating me, and to an explanation of their qualifications, title, and responsibilities. · To request at my own expense, the opinion of a consultant to review my treatment. · To my records being kept in a confidential manner. Though they are the property of Ms. Ford, I may request access to them by following the policies and procedures for such requests. · To be free from abuse, neglect, and exploitation. · To be treated without discrimination. · To make a complaint about my treatment and rights without such complaints being used against me. · To be honest, open and wiling to share my concerns with my counselor. · To ask questions when I do not understand or need clarification. To report changes or unexpected events as related to my problems with my therapist.
Normal sessions are 50 minutes in length. Payment for each session is due at the time of the visit. You will be charged for all scheduled appointments unless cancellation notice is received AT LEAST 24 HOURS PRIOR to the appointment time so that the time may be rescheduled.
My child’s records and/or any information conveyed by myself and/or members of my family to personnel at My Healing Place will not be released without my written permission unless required by Texas law. (Reporting alleged or suspected incidents of child or elderly abuse, suicidal ideation or gestures, sexual exploitation by a therapist or threats of harm to self or others is mandatory under the Texas Family Code.)
________________________________________________ ____________________ Signature of Parent/Guardian/Managing Conservator Date
________________________________________________ _____________________ Signature of Therapist/Witness Date |
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