Nahal Delpassand, PsyD, PLLC

Licensed Psychologist 1

600 W. 38th St. Suite 428

Austin, TX 78731

Adolescent Informed Consent Form

The purpose of meeting with a psychotherapist is to get help with problems or processes that are bothering you or interfering with being successful in important areas of life. You may have asked to meet with and talk to a therapist or this could have occurred because your parents, teachers, doctor or someone else has concerns about you. The process of therapy involves getting to know your perspective on these difficulties or predicaments in your life, developing an understanding of the nature of the difficulties, and generating better ways to cope with or manage those difficulties. Sometimes the predicament will disappear altogether, but other times learning to manage or cope with difficulties is a good outcome.

Sometimes these difficulties will include topics you do not want your parents or guardian to know about. For most people, knowing that what they say will be kept private helps with disclosing thoughts, feelings, and perceptions and to have more trust in their therapist. As a teenager, you have certain rights to privacy that are not equal to those of an adult (the legal definition of which is 18 years old), but privacy, also called confidentiality, is a critical part of effective psychotherapy. As a general rule, information you share in therapy sessions is confidential, unless you give consent to disclose certain information. However, there are exceptions to this rule that are important to understand prior to starting with the therapy process. In some situations it is required by law or professional guidelines that information discussed in therapy has to be disclosed. Some of those situations are described below. Most involve your protection and the protection of others from the potential to be hurt or harmed.

1. If you report having a plan to harm yourself, based on the evaluation of that plan, confidentiality can be broken in order to protect you from harming yourself.

2. If you report having a plan to harm someone else, based on the evaluation of that plan, confidentiality can be broken in order to protect the person you intend to harm.

3. If you are involved in activities that could cause harm to yourself or someone else, even if you do not intend to harm yourself or someone else, based on the evaluation of that behavior, confidentiality can be broken.

4. If you report that you are being abused - physically, emotionally or sexually – or that you have been abused in the past, the law requires that this be reported to the Virginia Department of Social Services.

 

5. If you are involved in a court case and a request is made for information about your therapy, information will be disclosed with your written consent unless the court requires that information be provided. If this occurs, you will be informed of the proceedings, and efforts to protect your confidentiality will be taken and discussed with you.

6. If you agree that information can be shared with a specific person or entity, then we will discuss the limits of what will be shared, and how that information will be shared.

Except for situations as described above, your parents/guardians will not be told of specific information you disclose in therapy. This includes activities and behavior that your parents/guardians would not approve of or be upset by, but that do not put you or others at risk for immediate harm. It may be important to let your parents know some information that is protected by confidentiality and you may be encouraged to share that information. Part of the therapist’s job is to discuss this with you and to decide together the best way to communicate the information.

Also, parents and guardians may be able to be more helpful if they have general ideas about themes of therapy (such as autonomy, important privileges, achievement, or the status of symptoms) and the therapist may have specific suggestions for parents that do not involve breaking your privacy. Parents are strongly urged to respect the privacy of your treatment and the related records.

Schools and Teachers. Information will not be shared with your school, including that you are even seeing a therapist, unless you and your parents/guardians give permission. If someone from your school wants to talk about your treatment, or if it is decided that talking to someone at your school would be beneficial, then you and your parents will be asked to give their permission for that. If your parents or school want information about the treatment, and you do not want to give permission, then that will be discussed in a session.

Physicians/Doctor’s Offices. Your medical doctor may have been involved in referring you for therapy, may have prescribed medication for you, or may be considering prescribing medication. Thus, it may be important to coordinate with your doctor or doctor’s office regarding your progress or status, especially when medication is involved or there are other health issues. Again, your permission will be required for such a consultation to occur and it will be important to discuss in therapy what information will be disclosed, especially since some information can be disclosed to a doctor that is not disclosed to your parents. The only time information can be shared with your medical doctor without your permission is if you are engaged in harmful or risky behavior that creates a concern about safety.

Below, you are asked to sign this form, as are your parents/guardians, and you can be given a copy of this if you would like.

eSignature of Client

eSignature of Parent/Guardian

PLEASE PRINT FORM BEFORE SUBMITTING

© 2018 by Dr. Nahal Delpassand