CONSENT TO TREATMENT - CHILD
| Patient's Name: |
|
| Child's Name: |
|
| Parent's Name: |
|
I understand and consent to the following:
1. I authorize and request my treating provider to carry out
psychological treatment.
2. I acknowledge that I am being informed that under California
law:
a. If a patient communicates to a therapist a serious threat
to harm an identifiable person, the therapist must warn that person and 
b. If the therapist suspects child abuse or neglect, or abuse
of a helpless adult or of an elder, a report must be made to the
c. If a patient seems dangerous to self or others or unable
to care for him/herself, then hospitalization may
3. I understand that:
a. Information and records--otherwise confidential--
concerning me and or my family must be provided in the event of a
b. I understand that Dr. Keller consults professionally
and confidentially
4. Parents and Guardians of Minor Children:
Communications between child and therapist are confidential except
under the exclusions given above. I understand that Dr. Keller is providing
psychotherapy and will not provide any custody evaluations or recommendations
of any kind regarding visitation or disputed arrangements between parents.
I agree that I will not request Dr. Keller's records for use in a custody
dispute. I understand that for treatment to be effective, I must cooperate
in working with Dr. Keller including meeting with Dr. Keller as requested.
Date
Parent
or GuardianWitness
5. My consent is for me and any minor children. Consent is voluntary and, except for Items 2 and 3 (limits on confidentiality) and urgent consultations, I may withdraw my consent to future disclosure at any time by writing a letter to Dr. Keller.
6. I have received a copy of this form.
Date
Parent
or GuardianWitness
This consent is in effect for the duration of treatment up to three years.