Counseling Consent Form

    COUNSELING CONSENT FORM

    Demographic Information

    Date:

    Youth's Name:

    D.O.B.:

    Gender:

    Ethnicity:

    Address:

    City:

    State:

    Zip Code:

    Home Phone:

    Cell Phone:

    Work Phone:

    Email Address:

    OK to leave messages? (Check all that apply)

    HomeCellText MsgEmailAll

    School:

    Grade:

    Referred by:

    Parent/Guardian Information

    Parent/Legal Guardian Name:

    Relationship:

    Parent/Legal Guardian Name:

    Relationship:

    Parent/Legal Guardian Name:

    Relationship:

    PLEASE NOTE: Only those who are legally authorized to make decisions about medical treatment for this minor child may consent to services.

    Tell us about some of the concerns you see?(Check all that apply)

    Anger ManagementAnxietyAbuse/ViolenceRunning AwaySocial SkillsDepressionInattentivenessSelf EsteemDisrespectfulJob Development SkillsHyperactiveTraumaBullyingFailing to Follow RulesPower/Control ChallengesFamily ConcernsWithdrawnEating DisorderPeer-Issues/Social SkillsSubstance AbuseGrief and LossAttachment IssuesSibling RivalrySchool-Related IssuesAdoption/Foster-care Adjustment IssuesCrisis InterventionRelationship Concerns

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    Tell us about some of the strengths you see?(Check all that apply)

    Curious and CreativeLove of LearningHonestKindSelf-ControlLeaderHobbies/PassionsShare Take Turns and CompromiseCopes When FrustratedLikes Community Service ProjectsEnjoys CookingLikes Talking to PeopleWorks on Difficult TasksGood ListenerExpresses Wants and NeedsGood Grades at SchoolAccepts Differences in OthersEnjoys ReadingLearn from MistakesHelp OthersSolve Puzzles or Word ProblemsEnjoys Video GamesMakes Friends and Keeps ThemHelpful at Home and Does ChoresGood Sense of HumorSings or Plays a Musical InstrumentPlays SportsFollows Rules and RoutinesMakes Good ChoicesFollow Rules and RoutinesEnjoys Drawing or DoodlingEnjoys MathDoes Not Argue with Adults

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    What kind of help would you like?(Check all that apply)

    AssessmentsCase ManagementChild PsychiatryBehavior SupportIndividual CounselingCrisis Residential ServicesIn-Home CounselingGroup Therapy to address above ConcernsMentoringParent Support GroupPsychoeducationIndependent Living ServicesFamily CounselingFamily Art TherapySubstance Abuse EducationRecreational TherapyDrug Prevention GroupsRelaxation TherapySkill Building/Community ActivitiesTrauma Focused CBTArt TherapyPositive Youth Development

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    CLIENT RIGHTS AND RESPONSIBILITIES

    As a client of St. Vincent Home for Children you have the following rights:

    1. The right to be safe, be heard and to be cared for

    2. The right to be treated with dignity and respect

    3. The right to be treated without regard to race, religion, gender, sex, age, marital status, national origin,sexual orientation, gender identity or expression, developmental disabilities, or mental or physicalhandicap.

    4. The right to have qualified, competent staff supervise and provide you with services.

    5. The right to therapy and a primary therapist to act as a confidant and advocate for you.

    6. The right to religious observance opportunities.

    7. The right to be free of physical and verbal abuse and corporal punishment.

    8. The right to be informed of expectations and consequences in your program.

    9. The right to privacy, given reasonable and practical limitations.

    10. The right to participate in your treatment planning and review.

    11. The right to refuse any unusual treatment or program including participating in research projects.

    12. The right to be free from exploitation in application for or in work itself.

    13. The right to protection of confidentiality within the parameters of State and National law and the right toinformed consent.

    14. The right to register a grievance or complaint and to be treated fairly in compliance with the agencygrievance procedure.

    As a client of St. Vincent Home for Children you have the following responsibilities:

    1. To keep yourself and others safe

    2. To listen and respect others

    3. To participate in your treatment and treatment planning

    4. To be open and honest in resolving any issues that arise

    The exercising of these rights may require responsibilities or consequences for your choices.

    INFORMED CONSENT FOR TREATMENT

    I affirm that I have been informed of the Home-Based Counseling Program and services provided by Saint Vincent Home for Children. I agree that St. Vincent Home for Children, its members, and agents have my full and free consent to perform such services as are deemed appropriate by the Home’s clinical staff in treatment of , and that there are no known side effects to therapeutic services. I understand that I am expected to be involved and and engaged throughout the duration of the program. St. Vincent Home for Children does not use any non-traditional, unconventional or controversial treatment modalities or activities.

    I understand and agree to these components of the Home-Based Counseling Program:

    • Youth will participate in weekly sessions and scheduled group activities based upon their treatment plan.

    • Parent(s) will participate in therapeutic services in-home or at a place of own choosing as needed based upon the youth's treatment plan.

      • Please select one:

      I understand and give permission to St. Vincent Staff and my children's school staff to provide and accept information that will assist with my child's assessments and/or treatment.I do not give permission to St. Vincent and my child's school to share information (Please note services may be limited if this area is checked because school collaboration is a vital ingredient to the success and outcomes of treatment)

      CONSENT TO TELEHEALTH SERVICES

      YesNo - I agree to participate as client of St. Vincent Home for Children telehealth delivery system. I will be receiving counseling services through interactive videoconferencing. I understand the use of videoconferencing is an alternative method of mental health care delivery and that my therapist/counselor will not be physically in the same room with me. I understand that although St. Vincent makes every effort to protect my privacy by using Zoom and a secure server, they cannot guarantee the security of any information I transmit to them over the internet. By using telehealth services, I recognize that transmissions over the internet are at my own risk and it is possible that third parties may unlawfully intercept or access the transmissions.

      I also understand that despite reasonable efforts on the part of my therapist, there are risks and consequences in using telehealth services. The risks include, but are not limited to, the possibility that the transmission of sessions could be disrupted or distorted by technical failures.

      In case of technical failures, my therapist/counselor will make every effort to re-connect with me. I also understand that telehealth services may not be as complete as services provided via face-to-face, although, several benefits of telehealth services have been identified, including increased access to specialized services in remote areas, lower healthcare costs, reduced travel, minimizing time off work, and decreased waiting time for services.

      I have also been notified that if my therapist/counselor believes I would be better served by another form of counseling services (e.g., face-to-face services), I will be referred to a therapist who can provide such services. Finally, I understand that there are potential risks and benefits associated with any form of mental health service and that, despite my efforts and the efforts of my therapist/counselor, my condition may not improve and in some cases could even get worse. I understand that my participation in this counseling approach is voluntary and I may decide to terminate my treatment at any time.

      My privacy and confidentiality will be protected. I understand that there will be no recordings of my sessions. I also agree not to record my own sessions without my therapist's/counselor’s knowledge or permission. I understand that the telehealth services will be provided to me free of charge. I give my consent to receive mental health services through the telehealth system. I also understand that the services I receive will become part of my treatment record at St. Vincent Home for Children.

      N/AYesNo - I understand that the Home-Based Counseling Program is funded through St. Louis County Children’s Service Fund and I understand that representatives of Children’s Service Fund can review my child’s file for compliance to Children’s Service Fund guidelines.

      In submitting this form, I am agreeing to services from St. Vincent Home for Children. I understand that the services received while in the program will be provided at no cost to me. This consent is valid through the final discharge date of the child.

      In submitting this form, I hereby acknowledge that I received a copy of St. Vincent Home for Children's Privacy Practices.

      Relationship to Child:

    Service Definitions

    Assessments: Children’s mental health assessments may involve a variety of testing including: an overall health assessment, psychological, vocational or other types of testing or assessments that look at your youth’s functioning across all environments such as the Child and Adolescent Needs and Strengths (CANS).

    Behavior Therapy: Behavior therapy is a broad term for treatment that focuses on youth’s behaviors and the thoughts and feelings that affect it. Behavior therapists also look at how the environment might have an impact on those behaviors. The basic goal of behavior therapy is to reinforce the behaviors you want to see and to eliminate the behaviors you don’t want to see. Behavioral therapy uses rewards and consequences to help children change their behavior and has been found to be effective in improving behaviors at home, school and the community.

    Case Management Services: This service is available for youth with mental health challenges and involves a case manager who works to ensure that the family and/or person-centered planning process occurs and that an individualized plan of services and support fits the needs of the youth and family.

    Child Psychiatry Services: Children and youth are referred to child psychiatrists for evaluation, consultation and, if needed, psychotropic medication.

    Cognitive Behavior Therapy (CBT): This type of behavioral therapy focuses on helping children and youth understand the thoughts and feelings that influence their behaviors. It is commonly used to treat a wide range of disorders including depression, anxiety and phobias. CBT teaches youth a different way of thinking, behaving and reacting to situations and can help them feel less irritable, anxious or fearful. CBT can also help young people recognize negative or unrealistic thoughts and turn them into more positive and realistic ones.

    Counseling: Individual and group counseling sessions are provided by trained counselors who can help youth cope with challenges in their lives, learn self-confidence and social skills, manage anger and emotions, and develop other positive life skills.

    Crisis Residential Services: Short term, out-of-home placements are intended to provide an alternative to inpatient psychiatric services for children who experience a sudden mental health crisis. The residential crisis service provider will partner with you and education services to ensure your child receives school services while receiving crisis services.

    Family Therapy: This type of psychological counseling is designed to help improve the way a family functions together. During treatment, a therapist will work with your family to improve your communication, relationships and help you to reduce and resolve conflicts within your home. Family therapy is usually provided by a psychologist, clinical social worker or licensed therapist. The therapist or counselor will look at your family’s strengths and interactions and then help you to reduce conflicts and address issues through a variety of strategies including: building conflict resolution skills, providing parent coaching and guidance, and helping you to improve family interactions as a way to reduce problem behavior. Your specific treatment plan and the things you work on with the therapist will depend on your family’s situation. Family therapy sessions can teach skills that can help you create strong supportive family connections which will help you to get through stressful times together, even after you’re done going to therapy sessions.

    Group Therapy: This form of treatment involves a small group of people with similar challenges who meets regularly to talk, and discuss issues with each other and the group leader (usually a therapist). The general purpose of Group Therapy is to create a safe and comfortable place where participants can work out problems and emotional issues, gain insight into their own thoughts and behavior, and offer suggestions and support to others. Young people who have difficulty with friendships or other relationships can often benefit from the social interactions that are a basic part of group therapy.

    Home-Based Services: These are intensive services provided in a family’s home and are considered an effective and essential service for children and youth with challenges. The services provided in your home will be individually designed for your youth and family and will focus on helping you and your youth deal with specific behaviors or problems. Examples of the types of services that may be provided include: mental health therapy, crisis intervention and other support services needed by the family. The goal of home-based services is to prevent your child from being placed outside of the home.

    Independent Living Services: These services provide support for a young person living on his or her own. These services include therapeutic environment, supervised housing, and job placement. Independent Living Services teach youth how to handle financial, medical, housing, transportation, and other daily living needs, as well as providing assistance to the young people as they learn how to live and get along with others.

    Individual Therapy: This form of therapy is sometimes referred to as psychotherapy or counseling. During Individual Therapy services, children and youth work one-on-one with a trained therapist to explore their feelings, behaviors and memories in a safe and caring, environment where they work to better understand themselves and others, set personal goals, and work toward the changes they would like to see in themselves.

    Mentoring: Youth Development Specialists work with a youth person intensively to increase healthy activity and involvement in school or the community.

    Parent Support Group: Parent Support Groups are provided as an addition to other treatments, and involves educating and coaching you as a parent to manage your child’s problem behaviors at home and school by using the principles of Learning Theory and Behavior Modification. Our groups help parents develop the special skills needed to successfully support and maintain their youth’s progress as they work toward making healthy life decisions.

    Psychoeducation: This support service involves providing information to the youth and their family about their mental health disorder(s) and the treatments and strategies used to manage its effect on their life. Being informed helps empower children, youth and their families and helps them to effectively manage their condition.

    Recreational Therapy: This treatment/service is designed to restore a young person’s level of functioning and independence in life activities they enjoy by promoting health and wellness and by supporting them by reducing obstacles to their participation in those activities.

    Relaxation Therapy: This is a broad term used to describe a number of techniques used to reduce stress, eliminate tension throughout the body, and help to create a peaceful state of mind. Relaxation Therapy has been shown to be effective for young people with anxiety and other disorders. Relaxation training can help a young person learn how to relax their mind and body by relaxing specific groups of muscles or by thinking of relaxing places or situations.

    Skill Building Assistance and Community Activities: These activities promote the integration of your child into the community. The therapist will assist your child to learn the skills they need to successfully be involved and engage in meaningful activities in their home, school and community.

    Substance Abuse Education: This service provides education and prevention interventions to help your child gain knowledge about the dangers of psychoactive substances such as prescription drugs, alcohol and street drugs like marijuana, cocaine, heroin or amphetamines.

    Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): This specialty treatment is designed for children who have experienced trauma. During TF-CBT, children and their families learn new skills to help process thoughts and feelings related to traumatic life events; manage distressing thoughts, feelings, and behaviors related to those events; and enhance safety, growth, parenting skills, and communication. TF-CBT has proven successful with children and adolescents who have significant emotional problems and symptoms of posttraumatic stress disorder, including fear, anxiety, or depression that are related to traumatic life events. Children or adolescents experiencing traumatic grief can also benefit from this treatment.

    Art Therapy: Is the use of creative techniques such as drawing, painting, collage, coloring, or sculpting to help people express themselves artistically and examine the psychological and emotional undertones in their art. With the guidance of a credentialed art therapist, clients can “decode” the nonverbal messages, symbols, and metaphors often found in these art forms, which should lead to a better understanding of their feelings and behavior so they can move on to resolve deeper issues.

    Positive Youth Development: Is an intentional, pro-social approach that engages youth within their communities, schools, organizations, peer groups, and families in a manner that is productive and constructive; recognizes, utilizes, and enhances youths’ strengths; and promotes positive outcomes for young people by providing opportunities, fostering positive relationships, and furnishing the support needed to build on their leadership strengths.

    If you are interested in any of these services, please feel free to give us a call.

    St. Vincent Home for Children
    7401 Florissant Rd.
    Saint Louis, MO 63121
    (314) 261- 6011

    The Core Collective at Saint Vincent
    7401 Florissant Road
    St. Louis, MO 63121
    Phone: 314-261-6011
    Fax: 314-385-1467
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