CONSENT FOR TREATMENT OF MINOR

I,  __________________________________________, give my consent that Matthew  Gerst, Ph.D. conduct psychotherapy with  _______________________________________, (DOB _____________).     

I am the legal guardian for this child/adolescent. My relationship to the client is:  ___________________________________________.

I have been notified and understand that all material discussed during the psychotherapy sessions  is confidential and can be released only with my permission.  I have also been informed of the limitations to the confidentiality in the Office Policies form that I have read and signed. These limitations include reasonable suspicion of child or elder abuse or neglect, where the client presents a danger to him/herself or others, is gravely disabled, or as a gravely disabled minor, pursuant to legal proceedings and when you have given permission and signed a Release of Information  form.

Privacy and trust are key components of the therapeutic relationship. Special sensitivity may be required in releasing information that the minor discloses in session about certain topics such as drugs and sex. I expect that Dr. Gerst will maintain my minor’s privacy and I will accept Dr. Gerst’s judgment in regard to releasing or sharing information obtained during the course of  psychotherapy with the minor that may endanger or jeopardize the patient’s well being.