Therapy Agreement and Informed Consent Notification

The Children’s Advocacy Center (CAC) is committed to providing high quality services to the children and families we serve.  Please review the following information with a CAC therapist.  If you have questions, please speak with the therapist directly before signing.

CLIENT POPULATION: The Children’s Advocacy Center (CAC) Serving Bastrop, Lee and Fayette Counties provides services to children ages 3-17 and their families who have survived or witnessed crimes of physical or sexual abuse, and/or experienced general trauma. Additionally, CAC provides support for the surviving family members of a child death.  Referrals are accepted from Child Protective Services, law enforcement, the District Attorney’s office, and from other professionals.  Individual families may also enlist our services. CAC provides services to non-offending children and parents, and does not provide services to alleged offenders on the property.  A referral list will be available for those clients that fall outside the scope of the population served at CAC.

CONFIDENTIALITY: All therapy sessions and written records are confidential with few exceptions as outlined below and will only be available to the clinical staff and Executive Director of CAC. If your therapist utilizes clinical supervision/consultation with professionals outside of this Center, they will discuss this with you when you sign your consent for treatment.

There are legally mandated EXCEPTIONS which require breaking confidentiality and do not require your permission:

1. CLIENT AUTHORIZATION:  Clients can give written consent for CAC to provide information to others (e.g. psychiatrists, doctors, case workers, etc.) in an effort to coordinate treatment.

2. In the instance of a person’s safety, the therapist, AS REQUIRED BY LAW, will need to make a report to an appropriate agency. These instances are:

a.  ABUSE OR NEGLECT:  If there is reason to believe that a child or elderly person has been or is going to be harmed, Child or Adult Protective Services will be called.

b.  IMMINENT RISK OF HARM:  If there is reason to believe that an individual may be at imminent risk of harming self, others, and/or property, then the counselor has the legal and ethical option to call the appropriate authorities.  This includes if an individual is actively suicidal or threats are made against another person.  Law enforcement can also be notified and/or summoned.

3. ORDERS FROM COURT OF LAW & CRIMINAL PROCEEDINGS:  If there is a court order to release information on records, as is sometimes practiced in legal proceedings, the agency and staff are legally bound to comply with the request.  For those cases in which there is a legal case pending, the therapist may be served by a subpoena to provide clinical records or testify in court.  The therapist will consider the request for information in regards to the client.  If the request is in the child’s best interest, the therapist will ask the parent/legal guardian to sign a release of information allowing him or her to share case information during the proceedings. 

If a release is not available or the therapist believes providing the information would be harmful to the client, the therapist may still be court ordered to share information. In this case, the therapist will be required to answer questions the court may ask. Only information asked by the court will be released in these circumstances.

 4. INAPPROPRIATE BEHAVIOR BY PREVIOUS THERAPIST: If a client discloses that a previous therapist behaved in a sexually inappropriate manner, then the current therapist is legally bound to report it to the District Attorney’s office as well as to the appropriate state licensing board. The client’s identity need not be disclosed if he/she does not wish it.

MULTIDISCIPLINARY TEAM MEETINGS: CAC is a partner agency with prosecution, law enforcement, Child Protective Services, medical professionals and mental health professionals in Bastrop, Lee and Fayette counties.  Occasionally other professionals in the community attend the Multi-Disciplinary Team (MDT) meetings, including Family Crisis Center, school staff and Juvenile Probation. The partner agencies have bi-weekly or monthly MDT meetings to staff cases that pertain to all attending parties. At least one member of the CAC clinical team attends these meetings and may disclose general information regarding your/your child(ren)’s case at the meeting on a “need-to-know” basis. Clinical staff members participate in MDT’s in a variety of different roles with different functions: therapists may represent clients in an advocate role as well as in a therapeutic role. When possible, any plan for disclosure of information at an MDT meeting will be discussed with parents/legal guardians and clients before the meeting.

APPOINTMENTS: Parents/legal guardians are expected to notify the Center within 24 hours for cancellation. After two missed sessions that are not cancelled in time or rescheduled, it is the CAC’s policy to consider termination of therapy services at CAC and provide appropriate referrals for other services. Your child’s therapist will discuss this issue with you should this situation arise.

FEES/No Call No Shows: Children’s Advocacy Center is a non-profit agency.  At this time, CAC is able to offer our therapy or related services at no charge.  However, there is a $20 fee for missed or late cancellation appointments. Late cancellation is anything less than 24 hours before the scheduled appointment.  Grant funding does not cover missed appointments and short notice does not allow the therapist an opportunity to fill the time set aside for your appointment. This fee must be paid to your therapist prior to scheduling another appointment.

SUPERVISION: Parents/legal guardians are responsible for supervision of children ages 0-14 while at CAC. Parents are to remain at CAC during their child’s session so that they are available in their child’s treatment as needed.

THERAPY:

Therapeutic Approach

The Clinical Department of CAC utilizes a strengths based, client-centered approach to therapeutic services. Families are supported holistically and empowered to guide and direct their own treatment needs. CAC clinicians strive to meet families wherever they are, aiming to provide a safe environment where healing can occur.

Services Provided

Many children and families come to the CAC after having experienced a great deal of trauma and stress. The purposes of the therapy services available at CAC are to help children and families to recover in the aftermath of a traumatic event. A CAC therapist will work with clients and parents/legal guardians to develop a treatment plan that specifically addresses the client’s needs. Types of therapy offered include individual, group, family and play therapy. CAC is able to offer these services in a short-term crisis-stabilization model as well as offer long-term therapeutic services.  Individual sessions will generally range from 30 to 50 minutes. The therapist will meet with family members on the initial visit and periodically throughout the term of counseling to discuss progress and/or to provide other support. The length of therapeutic services will be agreed upon collaboratively between all the signers of this Therapy Agreement with each client’s individual needs and goals in mind.

Potential Risks

In the course of a child receiving therapy services it is possible that issues that have remained unspoken for a long time will begin to emerge. As a result of the child processing some of his/her thoughts and feelings, he/she and/or the family may show behavioral indicators of stress.  Parents/legal guardians are encouraged to pay attention to these behaviors nd talk to your child’s therapist if there are any significant changes in the client.

Communication

Communication is a vital part of CAC’s therapy services. Your child’s therapist will make every effort to stay in touch with you, as it is CAC’s practice to maintain regular communication with adults that are in the child’s life.  It is important however, for the person in therapy to feel safe discussing issues that may arise in confidence.  In the interest of creating a safe and therapti environment for the child to work, it is CAC’s practice to maintain confidentiality with the child and consult with him or her before discussing information with family members.

Client/Therapist Relationship

Although clients may be sharing very personal information during counseling sessions, it is important to remember the professional nature of the therapeutic relationship. CAC’s experience demonstrates that clients are best served if the client-therapist relationship remains professional, and if sessions and contact are limited to those that support the goals identified in the treatment plan.

TERMINATION:     Parents and legal guardians of minor clients have the right to terminate services with the CAC whenever they choose.  However, should therapy be discontinued too soon, the child and family can experience a great deal of emotional stressors that may potentially

harm their well-being.  For this reason, it is recommended that therapy services continue untilall signers of the Therapy Agreement have decided termination is appropriate.  If you are concerned about the progress of therapy, you are encouragd to speak directly with your child’s therapist and/or the Clinical Director.

 There are a few situations in which a CAC therapist may determine the need to end the therapeutic relationship:

• If the therapy relationship becomes subject to a conflict of interest that may compromise the therapist’s ability to protect client confidentiality or remain therapeutically neutral, the therapist will refer the client to another agency or therapist who does not have such a conflict.
• If a CAC therapist decides to leave the agency before the client is ready to end therapy, he/she must give the client notice and provide referrals within or outside of the agency.
• If a client does not abide by the policies and procedures of the CAC (as set forth in this agreement) the therapist may end services.  This includes missing two appointments without notifying or rescheduling or not responding to two or more attempts to contact by phone.
• If it is determined that the client’s needs surpass the therapist’s ability to help, he/she must refer the client to a source of suitable help within or outside of the CAC.
• If the client no longer needs therapy and cannot benefit from continuing, the therapy relationship must end.
   

ALTERNATIVES/REFERRALS: In order to request a transfer to a different therapist, please see your child’s therapist or the Clinical Director at the Center directly.  Referrals can be made to another therapist or intern at the CAC or to a therapist in the community.  There are times when children and families require or desire therapeutic treatment beyond that which is available at this CAC. In these instances, clients will be referred to other agencies or professionals.

TREATMENT OF MINORS: The parents/legal guardians of minor clients have the right to request access to their child’s file.  If a request is generated, your child’s therapist will discuss with you the policies and procedures regarding access.

CLINICAL STAFF: Therapists each have a Master’s degree and are licensed in the state of Texas. CAC is also a training facility and has interns who are currently working towards their Master’s or Bachelor’s degrees. All interns are supervised by experienced, licensed therapists.

COURT SERVICES: All criminal court services will be provided to the client/victim at no charge. Civil court case fees will be the responsibility of the party processing the subpoena. Fee rate is as follows: $250 an hour with a four hour minimum, subsequent time needed for the case will result in $200 an hour. Minimum rate must be paid prior to the start of court proceedings. Communication with all parties involved will be included as billable hours in half hour increments with a minimum of 30 minutes.  Should your therapeutic services be rendered by an LPC-intern all CAC fees along with the fee schedule of the LPC-Supervisor will be collected prior to the court proceedings.  Should you have any questions regarding the fee schedule please feel free to contact the CAC Clinical Director at 512-321-6161. 

Emergency Contact

CAC requires that you give us contact information for a person we can contact in case of emergency. This contact will only be used if we believe you or someone else is in immediate danger or if you or your child becomes ill and unable to continue or depart therapy without assistance.

I have read and understand the terms of the Therapy Agreement.  Furthermore, I acknowledge that I have been given the opportunity to discuss and ask questions regarding the content of the Therapy Agreement.

I understand that my signature below indicates that I agree to receive therapy services for my child/ren and/or myself and consent to the terms presented.  My signature also indicates that I have received a copy of the Therapy Agreement.

of

do hereby request of and grant permission to

of the Children's Advocacy Center (CAC) Serving Bastrop, Lee and Fayette Counties to provide mental health services to the above-named client in order to assist in the promotion and maintenance of improved emotional, social and behavioral functioning.  I understand that this service may include methods of assessment, evaluation and counseling generally used by the mental health professions.

It is understood that CAC Staff will make appropriate referrals for services needed beyond those listed above.  I also understand that my child’s Therapist, in the course of providing assessment and/or counseling services, may seek consultation when necessary.  Consultation will be restricted to the Therapist’s professional supervisor and/or staff supervision.  I understand that like confidentiality laws also bind my child’s Therapist, supervisors and consultants.

I also agree and understand that my child and her/his safety is my responsibility while we are at the CAC and not in the therapy session with the Therapist.

I assert that I am this child’s parent and/or legal guardian and have the legal right to give permission for these services.

Therapy services at the Children’s Advocacy Center are grant funded, which means that there is no charge to the client; however, there is a $20 fee for missed or late (more than 15 minutes) appointments. Late cancellations are anything less than 24 hours before the scheduled appointment. Grant funding does not cover missed appointments and short notice does not allow the therapist the opportunity to fill the time set aside for your appointment. This fee must be paid to your therapist prior to scheduling another appointment.

I, the undersigned, understand that my or my child’s therapist is currently providing therapeutic services under supervision of:

I consent to the release of counseling session information for supervision purposes.  This supervision is a requirement for my or my child’s therapist in their route to successful completion of graduate school, professional license or other certification.  Furthermore, this supervision may be used to aid my or my child’s therapist to obtain effective support and consultation from another mental health professional.

I understand that the supervising therapist is under the same ethical and legal guidelines as other therapists, which requires information from a counseling session to be treated as confidential.

Furthermore, I understand that I have the right to refuse this request now, or at any time in the future with the understanding that a consequence may be a referral to another mental health professional.  In order to revoke this consent, I know that I need to contact the CAC Clinical Director and do so in writing.

I hereby acknowledge that I have received and have been given an opportunity to read a copy of the Children’s Advocacy Center (CAC) Serving Bastrop, Lee and Fayette Counties’ Notice of Privacy Practices.  I understand that if I have any questions regarding the Notice or my privacy rights, I can contact the Executive Director of the CAC who is the agency’s Privacy Officer.