Treatment of Minors

Client Name
DOB
  I, , give my consent for Elisa Elkin-Cleary, LICSW to assess and to provide psychotherapy treatment for my child, . I understand that I may stop treatment at any time and (minor) has the same right. I acknowledge that my child’s treatment is confidential, and that the full clinical record will not be shared with second and third parties. Information, specifically, assessments and treatment summaries, may not be released without my written consent except in the event stated under the confidentiality section. Elisa Elkin-Cleary, LICSW may determine with my child that my participation is needed to treat a specific problem. I acknowledge that in emergency/crises situations or if Elisa Elkin-Cleary, LICSW can not be contacted, I am responsible for my health and well being as well as my child’s health and well being. I acknowledge that my choices for immediate help and support are to proceed to my nearest hospital emergency room or to call 911/emergency number (if in the United States). My electronic signature represents that I have read and understood the above terms and conditions.
Signature of parent/legal guardian:    Date:
 
Signature of Primary Client: