Parental / Child Consent Form

Please read carefully and ensure that you understand this information before signing this form.

Information Guide for Child / Adolescent

All Hypnotherapy, Reiki, Qigong and Meditation sessions are designed to help you with issues in your life that you are having difficulty coping successfully with.

Our initial meeting will provide you with the opportunity to discuss any issues that you have without judgement.

As your therapist, I may need to gather further background information in order to decide on the best way of helping you to move forward in your life.

It is important that you feel comfortable with talking to me and that we develop a relationship based on mutual trust and respect.

During therapy, you may want to discuss certain issues that you would not talk to your parents or caregiver about.

As a general rule, any information you share with me will be private and confidential.

Exceptions to this rule could apply if:

I believe that as a result of your disclosure, you are putting yourself or others in danger of serious harm.
You have given permission for me to discuss personal information with your parent, guardian or another professional who is in a position to offer protection for you or the person in danger.
You tell me you are being abused, either physically, sexually or emotionally - or that you have been abused in the past.
You are involved in a court case and a request is made for information about your therapy.
If this happens, I will not disclose information without your written agreement unless the court requires me to.
I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening.

Communicating with your parent(s) or guardian(s)

If in my professional judgement, you tell me anything that I believe your parents, guardian, GP or school should know, in order to help your situation then I may encourage you to talk to them and will help you find the best way to tell them.

Adolescent Consent Form & Parent Agreement to Respect Privacy

Adolescent therapy client:

Please sign below to confirm that you have understood the information detailed above and the limits to confidentiality.

If you have any questions as we progress with therapy, you can ask your therapist at any time.

Please both Parent and Minor sign the form below.

Press “SUBMIT” to complete the form.

Parent/Guardian 1

Please indicate below your agreement to respect your adolescent’s privacy: I will refrain from requesting detailed information about the individual therapy sessions with my child and understand that I will be provided with periodic updates about my child’s general progress, and/or may be asked to participate in therapy sessions if/as requested.

Parent/Guardian 2

Please indicate below your agreement to respect your adolescent’s privacy: Although I am legally entitled to request written records/session notes since my child is a minor, I agree NOT to request these records unless I am duly concerned in order to respect my child’s confidentiality.

Parent/Guardian 3

Please indicate below your agreement to respect your adolescent’s privacy: I understand that I will be kept informed about any situations that could endanger my child or other/s. I understand that this decision to breach confidentiality under exceptional circumstances is up to the therapist’s professional judgment and may sometimes be made in confidential consultation with their supervisor or regulating body.

Parent/Guardian 4

I give Ryan Scott permission to conduct and use Hypnotherapy and/or Reiki, Qigong and Meditation strategies and interventions within my child’s sessions. (Please note if you would like more information with regards to what and how I use Hypnotherapy, Reiki, Qigong and Meditation, I would be more than happy to provide more details to you. Please let me know through email or mobile phone).

Minor Signature

Typing your signature is acceptable

Parent Signature

Typing your signature is acceptable

Date