Parental Consent to Treat a Minor (Separated, Shared Decision Making)

Conditions of treatment for a minor (play therapy) when parents are separated and sharing decision making.

I. Treatment


The child shall receive weekly, excepting vacations or illness, psychotherapy for reducing concerning behaviors and increasing desirable behaviors. A baseline of behavior will be established during intake by parent or parents reporting observations.

Parents will continue to provide for the child's participation in therapy for the duration without using the agreement as support for any other negotiation (e.g. If you ___, I won't bring the child to therapy).

No parent may end therapy unilaterally. Termination conditions are set forth below.

As much as possible the session time will be regular, as in on the same day and at the same time each week.

As MANDATED, Boulder Child Protective Services will be notified in the event a parent terminates treatment improperly. An attached relationship develops with the therapist and sudden interruption of that relationship is emotional abuse, for which reporting is mandated.

Parent Call:

Weekly "parent phone calls" will be arranged. The phone call is generally 30 minutes or less. The purpose of the phone call is for Andrew Rose, the treating therapist, to answer questions and share information regarding the child's participation in therapy, emerging themes, and to hear observations from both parents (if possible) regarding behaviors.

These calls are optional on both Andrew Rose's part and the parents' part. If a parent is unreliable in their reporting, uses the phone call to disparage the other parent, coaches or coaxes Andrew Rose, or expands the scope of the conversation beyond the behavior of the child or parent coaching, calls will no longer be scheduled.

Parents are entitled to know what happens in treatment and may request such information from Andrew Rose periodically (no more than once per session).

Mr. Rose is not a "conduit" through which to scare, denigrate, alienate, or otherwise emotionally abuse the other parent.

Communication between parents is NOT NECESSARY for the course of treatment and treatment will not be used to legitimize contact.

II. Payment

Due to the prevalence of financial disruption and entanglement in conflicted separation, fee will be negotiated separately with each parent.

Neither parent has the right to know the fee of the other parent.

Generally alternate sessions will be paid for by alternating parents, REGARDLESS of who is bringing the child. Andrew Rose will accept payment at the time of service through check, PayPal (credit cards), or cash.

III. The treatment will not be ended prematurely nor extended beyond necessity. Termination will be decided by the following factors:

a) The child's interest in treatment.

While resistance in early stages of treatment (before session 6) should be challenged, resistance in the "empowerment" stage should not. As the child is empowered to handle what was once overwhelming they will naturally be less interested in treatment and more interested in peer-related or self-directed activity. Their choice should be honored. For best outcomes, neither parent will pressure the child in any way to either stay in treatment or to terminate treatment. Parents will wait for the child to initiate such discussions.

b) Mr. Rose's expertise.

The child's behavior in the play room essentially induces in the therapist the difficulty the child has experienced. The treatment action is in the experiencing and processing of the emotional experience by the therapist in the field of the child. In time these "enactments" reduce as themes are processed. The child's maintenance, for a majority of the session, of play and relational styles that are chronologically age-appropriate is a marker of completion.

c) Evidence of the elimination or significant reduction in concerning behaviors.

The child's behavior will be observed by both parents for baseline behaviors (e.g. duration of melt-downs, occasions of dissociation, regressions, etc) and by Mr. Rose in the treatment suite. The child may also be observed by teachers and other contacts. Parents will be asked to sign disclosure agreements in the case of third party involvement.

Points of observation include both homes and school, and teacher input may be requested.

If the child's school is recommending or requiring participation in therapy, than this request by the school must be revisited before termination. If the child's behavior is not acceptable to reasonable child care professionals, more information will be sought and treatment will continue.

d) Failure of treatment and limit on treatment duration.

Due to the ongoing situation of conflictual separated parents (that may include disparagement, neglect, lying, parenting-by-proxy, exposure to dysregulated moods, etc.) the child may continue to psychologically defend from the pain of abandonment, rejection, neglect, confusion, and grief, etc. to the point where play therapy is ineffective.

After 40 sessions, either parent may terminate.

IV. Covenant not to sue, grieve, or file motions to end court ordered therapy.

Parent shall not commence or maintain any suit thereon against Mr. Rose whether at law or in equity.

Parent shall not grieve Mr. Rose to the Colorado Department of Regulatory Affairs for the direct or indirect purpose of prematurely terminating therapy.

Parent shall not commence any legal filing in order to prematurely terminate therapy.

This covenant shall be binding upon, and inure to, the benefit of the parties, their successors, assigns and executors, administrators, personal representatives and heirs.

V. Dispute Resolution

Any disputes regarding termination, or in excess of maximum limit for small-claims court arising out of this Agreement, shall be submitted to binding arbitration before a mutually agreed-upon arbitrator pursuant to the rules of the American Arbitration Association. The Arbitrator’s award shall be final, and judgment may be entered in any court having jurisdiction thereof. The client shall pay all arbitration and court cost, reasonable attorney’s fees, and legal interest on any award of judgment in favor of the therapist. All actions, whether brought by client or by therapist will be filed in Boulder County, Colorado.
This contract is held accountable to the legal system of Colorado and any applicable statutes held therein.

VI. Acceptance of terms

The action of the sending and receipt of this agreement via electronic method will hold both parties in acceptance of these terms. The Designer as sender and the client as recipient will acknowledge acceptance of these terms either through an e-mail noting acceptance or acceptance is acknowledged at the beginning of any work on said project. Electronic signatures shall be considered legal and binding.

VII. Participation by Andrew Rose in Third Party Investigations including Court.

Mr. Rose will participate in third party investigations given proper authorizations. These include general perceptions of parenting involvement, parenting skill, and psychological disposition of parents. Mr. Rose may be called on to opine or present facts to Parental Responsibility Evaluators, Child Family Investigators, Boulder Child Protective Services, Police Departments and other investigators.

Mr. Rose will make no determination regarding parenting time, as that is an issue for the courts to decide.

Parent Name: Parent Name

Child Name: child's name

Date of Signature Initiation: 1/1/2016

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