Minorsdonothave the legalstatus toenter intoawrittenagreementof informedconsentregarding thecounselingprocess,therisksandbenefitsofcounseling,andthelimitsofconfidentiality.Therefore,havingsigned Informed Consent regarding counseling services, I, __________________________________________, theparent/legal guardian of theminor, _____________________________________, givemy permission for him/her toreceivecounselingservices/treatments/assessmentsforthepurposeof:1. __________________________________________________________________________________________________________________

2. __________________________________________________________________________________________________________________

MinorsDONOThavelegalrighttoconfidentiality.However,toensure the integrityof thecounselingprocessandtoprovidetheminorwithanatmosphereoftrustwiththecounselor,confidentialityshouldbeprovided to theminor to the greatest extent possible.Regardless of the age of the client, confidentialityCANNOTbemaintainedunderthecircumstancesexplainedinthestandardlimitsofconfidentialitysharedontheinformedconsentform.Iagreethatthese limitshavebeenfullyexplainedbythecounselortotheminorinmypresence.Additionally,astheparent/legalguardian,IwishtoplacelimitsonconfidentialitybasedontheareasIhaveinitialedbelow.Thismeans thatshouldanyof the topics initialedbelowarise, Idesire tobe informedofsuchbythecounselor.Therefore,thecounselormaynotgiveassuranceofconfidentialitytotheminorinareas that havebeen initialed.By initialing certain issuesbelow, I acknowledge thepossible impact thismayhaveonmyminor’sabilitytofeelfreetofullydiscusshis/herfeelingsandthoughts,therebylimitingtheeffectivenessof thecounselingprocess. If Idonot initiala specific topic,andshouldsuch topicariseduringtherapywiththeminor,thecounselorwillattempttobringtheminortoapointwherehe/shecaninformmeoftheissue.Thecounselorwillattempttogainpermissionfromtheminortoinformmeoftheissue(s)aswell.Iunderstandthatanydisclosurethatfallsunderthelimitsofconfidentialitydiscussedinthestandardinformedconsent,regardlessofmyindicationbelow,willbereportedtomeimmediately.[]Illegaldruguse []Drinkinganddriving []Havingagunorotherweapon[]Tobaccouse []Gettingagirlpregnant []Planningtorunaway []Alcoholuse []Beingpregnant []Lyingaboutwherehe/shegoes[]HavinganSTD []Suicidalideation []Sneakingoutofhomeorschool[]Sexualbehavior []Sexualidentity/orientation []Other:_________________________MysignaturebelowmeansthatIhaveread,understand,andagreewiththeabovestatement:______________________________________ _______________________________________ ____________________SignatureofParent/Guardian SignatureofMinorClient DateI have discussed above statement with the signing adult. My observations lead me to believe that thisindividualisfullyauthorizedandcompetenttogiveinformedconsentfortheminorclient’scounseling._________________________________________ _____________________ SignatureofTherapist Date

StatementofConfidentialitywithaMinor