Consent To Treat Minor

Jeremy Cassius, M.Ed, LPC
4100 Spring Valley Rd, Suite #275 Dallas, TX 75244
PHONE:214-830-8214 | Fax: 866-242-3378

CONSENT TO TREAT A MINOR / CONFIDENTIALITY AND LITIGATION WAIVER

CONFIDENTIALITY AND THE TREATMENT OF MINORS: If your child is under eighteen years of age, please be aware that the law may provide you the right to examine your child’s treatment records. When I treat children under the age of 12, it is my policy to share all clinical information with the parents or legal guardians. For clients between the ages of 12 and 18, It is my policy, with your signed consent, to only provide general information about our individual work together, unless your child is suicidal or homicidal or engaging in “high risk” behaviors that may cause harm. In these instances, I will immediately notify you of my concern.

PERTAINING TO ADOLESCENTS BETWEEN THE AGES OF 12-18Because privacy in psychotherapy is often crucial to successful progress, particularly with adolescents, it is my policy to request an agreement from parents / guardians to waive their right to obtain information from records from Jeremy Cassius, M.ED, LPC pertaining to the evaluation and treatment of the above-mentioned minor children between the ages of 12-18 ( See Confidentiality and the treatment of minors). I will however provide you with general information about your adolescent’s progress, treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete with a written request to do so. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will immediately notify the parents of my concern. Before giving parents any information I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. Initials Here

PATIENT LITIGATION / ARBITRATION: Therapist generally, does not participate in any litigation or custody dispute in which Patient or Representative and another individual or entity are parties. Therapist will make efforts to be uninvolved in any custody disputes between Patient’s parents. Therapist will not voluntarily provide records or testimony unless compelled to do so. Should Therapist be subpoenaed or ordered by a court to surrender records, prepare documents, or to appear as a witness in an action involving Patient, Representative agrees to reimburse Therapist for any time spent for preparation, travel, or other time in which Therapist has made herself available for such an appearance. Fees for court appearance, testimony, deposition, attorney consultation and case preparation are $250.00 per hour including travel time, plus any relevant attorney fees incurred by Therapist. These fees are the separate responsibility of the Patient, Parent or Legal Guardian as applicable and are not reimbursable by insurance and must be secured by a prepaid retainer.

As indicated by your signature below, you hereby release, waive, discharge and covenant not to sue Jeremy Cassius, M.Ed, LPC in the event that she is compelled by a court of law to provide testimony or documentation that results in an unfavorable ruling, order, motion or modification, thus holding her harmless and free of any liability, damages, or costs, including court cost and attorney fees. Initials Here.