Treatment Of Minor Form

If you wish to download a PDF file of this form to print and complete by hand, click here.

Consent and Assent for Treatment of a Minor Client

This form documents that my adolescent-aged child and I have discussed the nature of and limits to confidentiality regarding communication between my child and the psychologist. We understand that although Arizona state law allows legal guardians the right to examine an adolescent's treatment records, The Nicholls Group request that the psychologist be allowed to use his/her judgment as to what information about an adolescent is shared with the guardian. We hereby agree that the psychologist will provide general information about the child's evaluation and/or treatment, unless the psychologist becomes concerned that the adolescent is at risk of or in danger, in which case the psychologist will immediately contact the guardian. The following laws also apply, and would result in this agreement beling cancelled:

Limits of Confidentiality by Arizona Law
  • There is reasonable suspicion of actual or potential child neglect or abuse (including physical, emotional, or sexual abuse, the witnessing of domestic violence, or the victim of a crime), in which case a disclosure to the office of Child Protective Services is required by Arizona Law.
  • The client communicates a direct, serious threat of physical harm to an identifiable victim or victims, in which case disclosure to the appropriate authorities is required by Arizona Law.
  • There is reason to believe that the client may be a danger to self, another, or another’s property, and that disclosure and or hospitalization is necessary to prevent that danger.
  • There is a valid court order
  • If the treating clinician should become aware that the minor is taking part in any consensual sexual or oral sexual activity and if the partners are between the ages of 14 and 17 years old, no report is legally required. However, sexual intercourse must be reported to the minor’s parents if either partner is under the age of 14 or if a minor under the age of 18 has a sexual partner who is 18 years or older; regardless of consent.
  • Both the minor client and his/her parents will sit in on the initial session to develop a written agreement about what will and will not be shared with the minor’s parents in terms of what is said in the therapy sessions. The exceptions to this are the state and federal laws, which were mentioned previously.

My signature indicates that I have read and understood the above agreement and give consent for my child to receive psychological services. My child’s and my signature also indicate that we agree to the above policy for treatment of a minor child.

My name as entered below will stand as my legal signature.