Consent for Child to Participate in Therapy/Assessment Services

As the parent(s) or legal guardian(s) with the authority to consent on behalf of the child named above, I hereby give my consent for my child to receive assessment and/or treatment from the professional staff associated with or employed by KIDTHINK. I understand that KIDTHINK is also a training facility, and that some services may be provided by graduate-level trainees or interns completing practicum or internship placements under the supervision of qualified professional staff. The KIDTHINK clinician responsible for mental health care will explain the proposed treatment plan, the general nature and extent of the risks involved in the treatment, and alternative treatment options, if any. I understand that I have a right to be informed about the specific nature of the service, that questions about this service are welcomed and that consent can be withdrawn at any time.

I am aware that in further discussions with the clinician, psychological and psychiatric consult, assessment or treatment may be recommended and may result in adaptions to the original treatment plan.

If you have a disagreement about the service that you receive that cannot be settled in discussion with the service provider, you may contact the Clinical Director of KIDTHINK for review. If the issue is not resolved satisfactorily, you may contact the professional body responsible for the type of services you are receiving for information or to make a complaint.

I understand that the mental health services provided through KIDTHINK are not intended for, nor shall be used for, litigation purposes.

Termination of Therapy

There are many reasons why therapy may end. A client or KIDTHINK may terminate at any time for any reason, including:

• The client has mental health needs that are beyond the clinician’s area of expertise. For example, the client requires a different level of treatment (e.g. family therapy, crisis intervention) or more specialized treatment (e.g., trauma or substance abuse) than the clinician provides in the practice setting.
• Clinician is unable or unwilling, for appropriate reasons, to continue to provide care (e.g., the clinician is no longer employed with KIDTHINK or breach of harassment policy).
• Conflict of interest is identified after treatment begins.
• Client fails to participate in therapy (e.g., non-compliance, no-shows, or cancellations).
• Lack of communication/contact from the client.

I understand that KIDTHINK will not abruptly terminate therapy and will attempt to communicate with the client in advance.

KIDTHINK is committed to providing a safe and respectful work environment for all employees, volunteers, board members and clients. KIDTHINK will neither tolerate nor condone behaviour that is likely to undermine the dignity or self-esteem of an individual. No one may be harassed, and no one has the right to harass anyone else at work or in any situation related to employment with KIDTHINK.

Family Situation

I understand that when the child's parents are living together and not separated, KIDTHINK will accept a signed consent for treatment of the child from either one parent. Consent may be withdrawn by either one parent at any time while services are being provided.

I am aware that in circumstances of family separation or divorce, consent will be required from all decision-making parties and copies of appropriate legal documents be provided to KIDTHINK. In high-conflict situations, additional consent may be required for services, and in cases of significant conflict dynamics, KIDTHINK may be unable to accept the referral if the presenting needs exceed the expertise of our clinicians.

Consent for Self

I am aware, in keeping with best practices, that it is the expectation for parent(s) or legal guardian(s) to participate fully in the child’s treatment plan. This may include parent support, coaching, treatment and/or assessment from the professional staff associated with or employed by KIDTHINK.

Consent for Teletherapy

Teletherapy services (also known as, telepsychology services) are a form of psychological service, as well as therapy services provided via secure internet technology. Due to the nature of the technology used, teletherapy services may be experienced somewhat differently than face-to-face treatment sessions. For example, there may be the potential for misunderstandings if visual cues are limited or absent in communications; thus, there may be a need to seek clarification when questions of misinterpretations arise.

Teletherapy involves arranging an appointment time between the client and the service provider when both parties can interface from their technology devices (e.g. computers, tablet, smartphone) via the internet.

You, the client, must be a resident of Manitoba and be physically located in Manitoba during the teletherapy sessions.

Please be aware that teletherapy is not suitable for all situations. The pros and cons of using teletherapy, based on the clinical issue, parent and child ability to benefit from the modality and access issues will be reviewed with you before proceeding. In addition, your clinician may request that you attend 1-2 sessions in person prior to proceeding with teletherapy sessions; this is decided on an individual basis by the clinician.

Clients who are actively at risk of harm to self or others are not suitable for teletherapy services. If this is the case or becomes the case in the future, speak to your treatment provider and more appropriate services will be recommended.

You have the right to withdraw consent to services at any time. Participating in therapy (face-to-face, or by teletherapy) can bring difficult feelings and experiences to the surface; this is a normal part of therapy, though can be challenging.

If you or your child experience symptoms that compromise anyone’s safety (e.g. considering suicide, violence or self-harm) outside of your appointment time, seek immediate attention by:

• Visiting your nearest hospital emergency room OR
• Calling 911 OR
• Calling Youth Mobile Crisis Team at 204-949-4777 or 1-888-383-2776

Fee Schedule and Appointments

This agreement outlines our shared commitment to the regular and timely arrangement of appointments at KIDTHINK Children's Mental Health Centre Inc., which is crucial for effective mental health treatment and support.

You will be provided with a fee schedule that is based on your gross household income, once you have provided the required proof of income to access the sliding scale. Please note that payment for all therapy services is due at the time the service is provided. You are responsible for submitting payment at each session you attend.

Understanding and Agreement: As a valued client, you agree to engage in regular sessions with your mental health clinician at least every six weeks.

Details of Scheduling:

• Initial Scheduling: Your first appointment will be arranged based on mutual availability when you begin services with KIDTHINK Children's Mental Health Centre Inc.
• Ongoing Sessions: After your initial session, you agree to arrange follow-up sessions every six weeks to ensure continuous support and adjustment of your treatment plan as needed.
• If you are accessing Fully Funded Client Care (FFCC) hours must be scheduled at a minimum of every two weeks to ensure consistent care, and clients are required to utilize the allocated 10 hours within a timeframe of 5-6 months, adhering to funding requirements and limitations.

How to Schedule:

• After each session, you will have the chance to book your next appointment directly with your clinician, adhering to the six-week guideline.
• If you're unable to schedule at the end of a session:
  1. Contact your clinician or the KIDTHINK office by phone or email to request a new appointment.
  2. Suggest preferred dates and times.
  3. We will collaborate with you to find a convenient time.
  4. Confirm your appointment once scheduled.

Changing Appointments: If you need to change or cancel an appointment, please notify us at least 24 hours in advance. This helps avoid any cancellation fees. Not rescheduling and failing to notify us may result in a charge equivalent to the session fee.

Appointment Reminders: We will send reminders via email or text message to ensure you remember your upcoming appointment.

Confidentiality

I understand that all information my child and I provide to KIDTHINK is confidential within the clinic. Exceptions to the confidentiality clause are suspected risk of self-harm or harm to others, disclosure of abuse and/or neglect, clinical supervision provided by contracted professionals, and if files are subpoenaed through the court system. The Protecting Children (Information Sharing) Act also allows for service providers to disclose information to another service provider if they reasonably believe the disclosure is in the best interests of the children. I understand that KIDTHINK will always endeavour to do so with parental permission and, at minimum, inform us of any disclosures made.

Analytics and Data Information

For the purpose of program evaluation and quality improvement, overall analytics and data information are collected. We may share data externally to our stakeholders for the purpose of advancing children’s mental health programs and services in our province and country. However, in all instances identifying information will be removed.

Consent for Electronic Communication

I consent to being contacted by the KIDTHINK team by email for the purpose of coordinating and managing services, including scheduling, follow-up communication, and sharing relevant service information.