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Informed Consent Form: Child Therapy: Separated/Divorced Parents

YOUR LETTERHEAD

Separated/Divorced Parents’ Agreement Form

I have brought my child ______________________, age _______, to Jane Smith, Ph.D., for evaluation and/or treatment. I understand that Dr. Smith’s patient is my child – not me, any other sibling, or my spouse. This is true no matter who pays Dr. Smith for the evaluation/treatment of my child.

I understand that Dr. Smith’s primary responsibility is my child’s best interest and that Dr. Smith may decide to involve me in my child’s evaluation/treatment at her sole discretion. I understand that if payment is not received promptly for services rendered by Dr. Smith to my child, the services may be suspended or terminated at Dr. Smith’s sole discretion, pursuant to the ethical guidelines governing psychological care.

I understand that Dr. Smith is not agreeing to be an expert witness or to testify on my behalf or on the behalf of any other individual other than my child at any deposition, court proceeding, or in any other way. I understand that Dr. Smith may or may not meet with me, my attorney, or any other party or attorney in any custodial or divorce proceeding at her sole discretion. Dr. Smith may also charge for the receipt of any correspondence or acceptance of any telephone calls, other than those directly from the court or counsel for my child.

I have read the above paragraphs and understand them. By signing below, I agree to the above.

Date ______________ _______________________________________ (SEAL)

Date ______________ _______________________________________ (SEAL)

Date ______________ _______________________________________ (SEAL)

Date ______________ _______________________________________ (SEAL)

NOTE: This is a sample form, designed for training purposes.
To the best of our knowledge, it is consistent with Virginia laws and regulations.
However, for use in your own setting, this form must be personalized
to reflect your state’s laws and your own actual policies.
(*Choice of sentences must reflect your own actual practices in working with couples.
If neither sentence applies, you should supply wording to describe your approach.)

Drafted for The Center for Ethical Practice, Inc.
by Bernadette Landolf, Ph.D.
She can be reached at 703.860.2010