Bringing your child to therapy is a great decision. Many of our mental health issues start from early on and can be prevented in developing future, if early intervention is in place. This is a decision many parents wouldn’t make early enough, so we thank you and sincerely congratulate you! Having said this, you need to be informed of the risks involved in bringing your child to see a psychologist. This form is to help you understand some of the risks involved, and to ensure both parents are on board in this understanding. At any time, you can ask your clinician questions about your rights, responsibilities and risks.
Your child's full name*
What is your relationship to the child*
Your relationship to the child*
Who will be coming with the child to the appointment?*
Who will be coming with the child to the appointment - Others*
Marital status of parents*
Do both parents consent to the child attending therapy?*
Please be aware that we are usually unable to accept a referral if both parents do not consent to the child being in therapy. It is in the best interest of the child that both parents are on the same page, even if they are separated. Seeing children without the consent of one parent can create distress for the child. Due to this complexity, this is a context that we do not work in here at Therapy House. We recommend a more specialised service, for example a forensic psychologist who works with families (E.g., https://www.familychildconnect.org.au) If you believe there are reasons that you would like us to accept the child in therapy, please indicate them below and we will get back to you to discuss.
Other Parents Detail
We do need both parents consent to therapy before we are able to proceed. Please forward the child’s other parent the link below and ask them to sign the form and submit it to us, alternatively you can ask Therapy House reception to send them the consent form.
Other Parent Name*
Parents*
Email*
Therapy Detail
What are your therapy goals for your child?*
Are there any court orders in place?*
Please send us a copy of the court order. To help us determine what rights each parent has and if both parents have equal rights, please inform the other parent as it’s important for the child in therapy that both parents are in the loop.
Legal Detail
Are there current custody proceedings regarding the child, and/or their siblings?*
Please Specify*
Are there any other relevant legal matters pertaining to the parents (and/or child)?*
Please Specify*
Parents Communication
Both parents have the right to book a session and bring their child to therapy (in the absence of court orders). We will accept children coming to their session with either parent, but we would like the parents to inform each other of this decision. If at any time either of you would like to request a list of appointments, you can send an email to us and ask for this.

Any important communication will be shared between both parents and will be emailed to both parents. Non-critical emails such as appointment reminders will be sent to one parent only. Usually this is the accompanying parent because they need to confirm appointments. Please indicate who will receive appointment reminders.
Parent*
Name*
Email*
Session notes, parent’s rights and record keeping
We take notes to remember important information, formulate therapy, and help inform other therapists that you may work with in the future. Notes are usually broad and don’t include details of what is discussed in session.

Notes can be sought by either parent at any time (until the child is at a legal age). They can also be subpoenaed by courts in legal situations, including situations that may arise in the future. However, our notes are not written for the purpose of use in court, such as child custody proceedings. As such, parents should be aware that
1. Most importantly, when writing notes, we consider the best interests of our client. First and foremost, your child is considered the client, and therefore we focus on what is in the best interests of your child and involve parents accordingly. However, if there is something you don’t want written down, you can inform us and we will discuss risks and benefits of how this is recorded.
2. Even though this might not be relevant to you now, it might become relevant in the future so please seek clarifications from your therapist, about how records an affect your rights in some circumstances.
3. If you write us emails, these emails might be kept on file and therefore become a part of clinical files, and could be sought by your child, the other parent, or legal representatives in the future. Pease keep this in mind when writing sensitive information in the emails.
4. Therapy House is unable to take referrals where therapy is intended for this purpose.
5. Most often, seeking clinical notes from a psychologist will not help you with custody and court related issues. If this is your aim for being in therapy, please keep in mind that our notes will be broad and therapy related without judgment or recommendations.
Informed Consent*
- I Agree - I have read and understand the above information (including that pertaining to session notes and records) and hereby give consent to my child attending therapy. I understand that I am encouraged to discuss my rights and risks with my therapist, before deciding to commence therapy.
Please type "I AGREE" for signature*
Your name*
Date*

Other Parents Detail

Therapy Detail

Legal Detail

Parents Communication

Session notes, parent’s rights and record keeping