CHAMPION PSYCHOLOGICAL SERVICES, LLC

P.O. Box 2623Mercerville, NJ 08619

P:609-638-7560 / F:609-581-4762

MINOR CONSENT TOTREATMENT

I give Champion Psychological Services,LLC my consent to treat my child. If we are treating your child, we will do our best to accurately diagnose them and design a comprehensive treatment plan that will enable your child to continue with a normal emotional development.This may include recommendations of therapy, medications, and/or calling the school to try and help arrange your child to receive optimal education. This is all part of the service of a mental health professional. We will also work with his/her primary care physician to assure coordination of care.

It is important to note that when we are seeing your child, you consent to treatment for them. They are our client and have confidentially rights. Confidentiality does not apply under certain situations: We are obligated by law to report any suspicion of child abuse. This includes physical or sexual abuse. Also, we have a duty to protect if we suspect anyone is in danger of killing themselves or has made threats to hurt someone else. Except in these rare situations, your child has the right to keep topics confidential from even his/her guardian. Please respect this confidentiality. Again, if there is any concern of harm, suicide,or other dangerous behavior, we will inform you.

If I require or think it is in you or your child’s best interest to communicate with an outside source, such as his/her school, I will request a release of information. We do not perform custody evaluations. If there is a question of custody, there will need to be a separate, neutral evaluation that both parties can agree on. To assure good therapeutic care, frequent appointments are required. Unless arranged otherwise, clients that have not been seen in 3 months will be considered inactive. A new evaluation will be required for any inactive client to be seen.