Parent/Guardian Counseling Services and Telehealth Agreement

Please take a moment to complete this confidential agreement and questionnaire for counseling services for a child. Your information will not be shared with anyone outside of the Living Well Cancer Resources.

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  • We realize that having your child begin counseling is a major decision and you may have many questions. This document is intended to help answer some of those questions for you by informing you of our policies, State and Federal Laws, and your rights.

    Our Staff. All counselors at Living Well Cancer Resources have earned a Master’s degree and are licensed by the State of Illinois as a mental health clinician. A copy of the counselor’s Professional Disclosure Statement is available to you upon request.

    Office Hours and Emergencies. Living Well counselors are available for appointments during normal business hours, Monday through Friday, with some evening hours available. Living Well is not a crisis center and is not equipped to provide emergency or crisis counseling. If you are experiencing a medical or mental health crisis or emergency, please call 911 or go to the nearest emergency room.

    Appointments. Living Well is able to provide an individual with a maximum of 20 sessions. The appropriate length of a session for a child may range from 30-50 minutes, based on the discretion of the clinician. Please provide 24 hours advance notice if your child will need to miss an appointment. Email is best for quick, administrative needs such as canceling or rescheduling an appt. If you need to discuss something in more depth with your child’s counselor, please reach out via phone or wait until your child’s next scheduled session.

    Benefits and Emotional Risks. The involvement of children in therapy can be highly beneficial to their overall development. Very often, it is best to see them with parents and other family members; sometimes, they are best seen alone. I will assess which might be best for your child and make recommendations to you. Obviously, the support of all the child’s caregivers is essential, as well as their understanding of the basic procedures involved in counseling children. The general goal of involving children in therapy is to foster their development at all levels. At times, it may seem that a specific behavior is needed, such as to get the child to obey or reveal certain information. Although those objectives may be part of overall development, they may not be the best goals for therapy. Again, I will evaluate and discuss these goals with you.

    Coordination of Care. Because my role is that of the child’s helper, I will not become involved in legal disputes or other official proceedings unless compelled to do so by a court of law. Matters involving custody and mediation are best handled by another professional who is specially trained in those areas rather than by the child’s therapist.

    If your child has been in counseling or psychotherapy in the past and/or are currently receiving other relevant services elsewhere, your child’s counselor may find it important or beneficial to communicate with the other professionals involved in your child’s care and/or receive copies of their records. In the event that you and your child’s counselor deem it important to communicate with these professionals, your counselor will ask you to sign a Release of Information form so they can communicate with those individuals.

    Client Rights. As the parent/guardian, you may end the counseling relationship with your child’s counselor at any time. If you choose to end the counseling relationship, your child’s counselor may ask that your child participate in a termination session. You also have the right to refuse or to discuss modification of any counseling technique or suggestions that you believe might be harmful. Living Well counselors render counseling services in a professional manner consistent with accepted ethical standards. If at any time for any reason you are dissatisfied with the services you are provided, please let your child’s therapist know. If you are not able to resolve your concerns with your child’s therapist, we encourage you to report your complaints to Living Well’s Director.

    Referrals. Living Well Cancer Resources offers counseling that focuses on the impact of a cancer diagnosis. Some clients achieve their goals in only a few counseling sessions, whereas others may require time that extends beyond what you and your child’s counselor are able to address in your allotted 20 sessions. If you and/or the counselor believe a referral is needed, your child’s counselor will provide you with information on other mental health professionals, agencies, programs and/or people in the community who may be able to assist you in properly addressing your child’s needs.

    Confidentiality In Counseling with Children. The issue of confidentiality is critical in treating children. When children are seen with adults, what is discussed is known to those present and should be kept confidential except by mutual agreement. Children seen in individual sessions (except under certain conditions) are not legally entitled to confidentiality (also called privilege); their parents have this right. However, unless children feel they have some privacy in speaking with a therapist, the benefits of therapy may be lost. Therefore, it is necessary to work out an arrangement in which children feel that their privacy is generally being respected, at the same time that parents have access to critical information. This agreement must have the understanding and approval of the parents or other responsible adults and of the child in therapy. This agreement regarding treatment of children has provisions for inserting individual details, which can be supplied by both the child and the adults involved. However, it is first important to point out the exceptions to this general agreement. The following circumstances override the general policy that children are entitled to privacy while parents or guardians have a legal right to information. Confidentiality and privilege are limited in cases involving child abuse, neglect, molestation, or danger to self or others. In these cases, the therapist is required to make an official report to the appropriate agency and will attempt to involve parents as much as possible.

    Children may independently enter into therapy and claim the privilege of confidentiality in cases involving abuse or severe neglect, molestation, pregnancy, or communicable diseases, and when they are on active military duty, married, or officially emancipated. They may seek therapy independently for substance abuse, danger to self or others, or a mental disorder, but parents must be involved unless doing so would harm the child. Any evaluation, treatment, or reports ordered by, or done for submission to a third party such as a court or a school is not entirely confidential and will be shared with that agency with your specific written permission. Please also note that I do not have control over information once it is released to a third party.

    Living Well is a HIPAA mandated organization and counselors strictly adhere and are compliant with all standards. If you wish to see a copy of Northwestern Medicine's HIPAA policy, it will be available to you upon request.

    Now that the various aspects surrounding confidentiality have been stated, the specific agreement between you and your child follows:

    I agree that my child should have privacy in his/her therapy sessions, and I agree to allow this privacy except in extreme situations, which I will discuss with the therapist. At the same time, except under unusual circumstances, I understand that I have a legal right to obtain this information. I will do my best to ensure that therapy sessions are attended and will not inquire about the content of sessions. If my child prefers not to volunteer information about the sessions, I will respect his/her right not to disclose details. Basically, unless my child has been abused or is/are a clear danger to self or others, the therapist will normally tell me only the following: whether sessions are attended whether or not my child is generally participating whether or not progress is generally being made The normal procedure for discussing issues that are in my child’s therapy will be joint sessions including my child, the therapist, and me and perhaps other appropriate adults. If I believe there are significant health or safety issues that I need to know about, I will contact the therapist and attempt to arrange a session with my child present. Similarly, when the therapist determines that there are significant issues that should be discussed with parents, every effort will be made to schedule a session involving the parents and the child. I understand that if information becomes known to the therapist and has a significant bearing on the child’s well-being, the therapist will work with the person providing the information to ensure that both parents are aware of it. In other words, the therapist will not divulge secrets except as mandated by law, but may encourage the individual who has the information to disclose it for therapy to continue effectively.

    Counseling Relationship. The counselor’s relationship with your child is professional in nature. As such, your child’s counselor may not interact with you or your child on personal social media or accept gifts. Additionally, in adherence with confidentiality, in the event that you see your child’s counselor in a setting outside Living Well or outside of a professional context, the counselor will not initiate acknowledgment of you or the child as your counseling relationship is confidential. You are, however, welcome to approach the counselor or initiate conversation.

    Telehealth Services
    In addition to office-based appointments, Living Well provides individuals the option to conduct counseling sessions via telehealth, either as phone-based appointments or video based appointments utilizing the HIPAA compliant platform, Microsoft Teams.

    There are possible limitations to telehealth care, including:

    • Sessions may lack video and/or audio cues, which may cause misunderstanding
    • Sessions may have disruptions due to the service and quality of technology used
    • Sessions are not appropriate if your child is having a crisis, acute psychosis, or suicidal/homicidal thoughts. In such instances your child’s therapist will talk with you about a higher level of care outside of Living Well and when symptoms have stabilized, resuming care at Living Well through in-person sessions in place of telehealth based sessions

    There are also potential risks unique to telehealth counseling. When technology is used for communication of any kind, there is always the risk it may be forwarded, intercepted, circulated, stored, or even changed and the security of the devices used may be compromised. Although we make every reasonable effort to protect the privacy and security of all electronic communication we have with you, it is not possible to completely secure the information. With the use of technology, it is important to be aware that family, friends, co-workers, employers, and hackers may have access to any technology, devices, or any other device you know is safe. You are responsible for reviewing the privacy sections and agreement forms of any application and technology you use. Please contact us with any questions that you may have on privacy measures.

    Parent/Child responsibilities for telehealth appointments include:

    • Avoid the use of mind-altering substances prior to or during session
    • Dress appropriately during session (shirt and pants required)
    • Not bring any weapons of any kind to session
    • Not record sessions without first obtaining the therapist’s approval
    • All telehealth clients should:
      • Be in an area that is safe and provides privacy
      • Be in an area that is appropriate for a web-based session
      • Not have anyone else in the room unless you first discuss it with your child’s clinician
      • Not conduct other activities while in session, such as driving
      • Be located within the state of Illinois or in a state in which the treating professional is licensed
      • Have a parent or guardian with them at the location/building of the telehealth session, unless otherwise agreed upon with the therapist and client

    So that the clinician can get your child help in case of an emergency and for your safety, the following are important and necessary:

    • You, the parent will inform the clinician of the location in which you and your child will be consistently during their sessions, and you will inform him/her if this location changes.
    • The parent will identify on their child’s intake form a person whom the clinician can contact in the case that he/she believes they are at risk (emergency contact)
    • Depending on the assessment of risk, you, the parent, or your child’s clinician may be required to verify that your child’s emergency contact person is able and willing to go to your location in the event of an emergency, and if your child’s clinician deems necessary, call 911 and/or transport you to a hospital.

    In the event of technology failure, your child’s counselor will make every effort to get in touch with you through an alternate means of communication.

    • For video sessions: we ask you to end and restart the session. If you are unable to reconnect within five minutes, your child’s counselor will call and/or email you at the phone number and/or email address you listed on your child’s intake paperwork. Please have this phone and access to your email account available to you during session time.
    • For phone sessions: your child’s counselor will attempt to call you back at the same number if the call is disconnected. If you and your child’s clinician are unable to connect again on the phone, the clinician will send you a message via email to follow-up.
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  • Parent/Guardian Counseling Intake Questionnaire

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