Informed Consent For Psychotherapeutic Treatment With Minor Patients
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ScribdTranslationsInformed Consent For Psychotherapeutic Treatment With Minor Patients
Uploaded by
ScribdTranslationsINFORMED CONSENT
OF PSYCHOTHERAPEUTIC TREATMENT WITH
MINOR PATIENTS
Last Name and First Name of the Patient ...............................................
National ID: ..................................
Mr. ____________________________________________________________________
of legal age, residing in the city of ____________________, in the neighborhood of
___________________street __________________No ____________ floor ________
Dept. ________, father of the minor ___________________ and
Mrs. ____________________________________________________________________
of legal age, residing in the city of ___________________, in the neighborhood of
___________________ street________________ No. __________ floor ________
Dept. _________, mother of the minor ____________________________ or in their
defect, the tutor of the minor, whose name is _____________________ older than
age, residing in the city of ____________, in the neighborhood of ______________
street ___________________ No. ___________ floor ________ Dept. _______
they manifest the veracity of the personal data provided for the
preparation of the medical history, and leaves/leave evidence of having received
sufficient information about the psychological treatment that will be conducted by the
patient_____________________ years old1, having understood the
Operating rules and being satisfied with the explanations
provided. For such purposes, they voluntarily grant their consent for the
implementation of the therapeutic process, according to the conditions that are transcribed to
continuation:
QUESTIONS RELATING TO THE CHARACTERISTICS OF THE TREATMENT
A psychological treatment will be carried out, which will focus on addressing
the reasons for the consultation presented.
2. The therapeutic approach will be appropriate for each clinical situation and is inscribed
From the age of twelve, the opinion of the minor must be considered.
much more decisive the older they are and their ability to
discernment.
within the framework of psychotherapy that has the best results for
problem in question.
3. I hereby acknowledge that I have been informed of the characteristics
techniques of the approach to be applied and all doubts have been answered
relevant.
MATTERS RELATED TO THE DURATION AND MODE OF TREATMENT
The treatment will be carried out with a specific indicated frequency.
by the treating professional. Consultations have an average duration of 50
minutes, which may vary depending on what happens during that time.
In this case, the patient will attend ______ weekly session/sessions of _____
minutes in duration.
The duration of the treatment will be as long as the professional deems necessary according to
to the problem that the consultation has generated. In this case, a deadline was agreed upon.
of ____________ months, which can be modified (extended or shortened)
through a new agreement, based on the degree of progress in the
fulfillment of the established objectives.
3. The absence from two consecutive interviews without effective notice from
of the patient, will be interpreted as a abandonment of treatment and could
to dispose of the scheduled timing, considering the treatment finished.
MATTERS RELATED TO FEE PAYMENT
1. Assistance is provided through the payment of a fee per interview, whose
The amount will be agreed upon with the treating professional. If for any reason you
If you have difficulties with the payment of the fee, you must inform the professional.
that circumstance to be taken into consideration. In this case
The fees are $_________ per session. They may be modified.
by mutual agreement during the course of the treatment.
The patient is financially responsible for the scheduled space even though not
it runs, unless there is effective communication with the professional with
less than 24 hours in advance and this find it appropriate to propose a schedule
alternative for the interview.
QUESTIONS RELATING TO THE EVOLUTION OF TREATMENT
The treatment may be unilaterally interrupted by the patient in
the moment I consider it appropriate, informing of this decision to the
professional practitioner, who will assess whether this interruption may be harmful
for themselves or for third parties. Reserving the right to notify whoever
consider yourself responsible.
2. Confidentiality is guaranteed regarding the information received by the
patient, whose limit can only be breached for just cause according to the
established in the code of ethics of the practice of the profession. This means that
the information provided to the psychologist during the therapeutic process
is subject to professional secrecy and therefore cannot be disclosed to
third parties without the explicit consent of the patient or those who are in their
The psychologist is required to disclose to the authorities
timely confidential information in those situations that could
to represent a very serious risk for the patient themselves or for third parties
persons or because it was ordered judicially. In the event of
that the judicial authority requires the disclosure of any information, the
The psychologist will be obliged to provide only that which is
relevant to the matter at hand while maintaining confidentiality of
any other information. As parents you will be informed of the aspects
related to the therapeutic process and its evolution, maintaining as
the data that has been agreed upon between you shall be confidential,
the patient and the therapist2.
3. The patient is responsible for following the therapeutic instructions given by the
the treating professional provides: inter-consultation with medical professionals and non-medical ones
doctors and possible institutional referral.
4. In case the psychologist deems it necessary, indicate if
they consent or do not consent to the possible recording of the session by means
audio-visuals for your personal review.
The aspects that will be reported to the parents and those of which they will be informed.
will maintain confidentiality and will therefore be restricted to the relationship
between the minor and the therapist, will be agreed upon in advance after a negotiation in the
that will involve all stakeholders (parents, minor, and therapist).
Place: .................... Date: …/…./….
Patient's signature: Signature of the Professional:
Clarification: Clarification:
D.N.I. ID Card:
Father's signature: Mother's signature:
Clarification: Clarification:
DNI ID Number:
Signature of the Responsible Tutor:
Clarification:
Relation/Relationship:
ID:
