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1. Identification of Parties: Details of the therapist, child client, and parent(s)/legal guardian(s) including full names, contact information, and relationship to child
2. Purpose of Therapy: Clear explanation of the therapeutic services to be provided and their intended purpose
3. Consent Declaration: Explicit statement of parental consent for the child to receive therapy services
4. Rights and Responsibilities: Outline of the rights and responsibilities of all parties involved, including the right to withdraw consent
5. Confidentiality Statement: Details about privacy policies, limits to confidentiality, and information sharing practices
6. Emergency Procedures: Protocol for emergencies during therapy sessions and crisis situations
7. Financial Agreement: Information about fees, payment policies, and cancellation procedures
8. Duration and Frequency: Expected length and frequency of therapy sessions
9. Communication Policies: Guidelines for communication between sessions and contact procedures
10. Signature Block: Space for dated signatures of all parties, including witness if required
1. Custody Agreement Reference: Required when parents are separated/divorced to confirm authority to consent to treatment
2. Telehealth Services: Include when virtual therapy sessions are offered as an option
3. Recording Consent: Include if sessions may be recorded for training or supervision purposes
4. Group Therapy Provisions: Required when group therapy is part of the treatment plan
5. Research Participation: Include if there's possibility of using anonymized data for research
6. Insurance Billing: Include when therapy may be covered by insurance
7. Medication Management: Required when therapy includes coordination with psychiatric services
1. Schedule A - Fee Schedule: Detailed breakdown of all possible fees and payment terms
2. Schedule B - Clinic Policies: Detailed clinic policies including attendance, cancellation, and safety protocols
3. Schedule C - Privacy Policy: Detailed privacy policy and information handling procedures
4. Appendix 1 - Emergency Contact Form: Form for recording emergency contact information and medical alerts
5. Appendix 2 - Release of Information: Optional forms for authorizing information sharing with specific parties
Healthcare
Mental Health Services
Social Services
Education
Child and Youth Services
Private Practice
Medical Clinics
Counseling Services
Family Services
Community Health
Legal
Clinical Operations
Mental Health Services
Administrative Support
Quality Assurance
Risk Management
Client Services
Compliance
Healthcare Documentation
Practice Management
Psychologist
Clinical Social Worker
Mental Health Counselor
Family Therapist
Child Psychotherapist
School Counselor
Clinical Director
Practice Manager
Healthcare Administrator
Legal Compliance Officer
Risk Management Specialist
Mental Health Practice Owner
Clinical Supervisor
Youth Support Worker
Behavioral Therapist
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