Consent Form for Psychotherapy: Adolescent Participation

Overview of Treatment Approaches:

• Psychotherapy: Talk therapy to explore and address emotional and behavioral challenges.

• Music Therapy: The use of music (listening, playing, improvisation, songwriting, etc.) to express and process emotions, enhance well-being, and promote healing.

• Humanistic Gestalt Therapy: A therapeutic approach that focuses on increasing self-awareness and understanding emotions and behaviors in the present moment.

• Mindfulness-Based Cognitive Therapy (MBCT): Combines mindfulness practices with cognitive therapy techniques to address anxiety, depression, and unhelpful thinking patterns.

• Cognitive Behavioral Therapy (CBT): Focuses on identifying and challenging negative thought patterns and behaviors, and replacing them with more adaptive, positive patterns.

• Family Systems Therapy: A therapeutic approach that views individuals within the context of their family dynamics. It helps to understand how family relationships impact individual behavior, emotion, and well-being, and works to improve communication, boundaries, and overall family functioning.

Informed Consent for TreatmentI, the undersigned, am the legal parent or guardian of the adolescent named above and give my consent for the adolescent to participate in psychotherapy, music therapy, Humanistic Gestalt therapy, MBCT, and CBT with Dr. Alaina Patrick, Founder of The Therapy Experience. I understand the nature of the therapies and agree to the following:

1. Purpose of Therapy: The purpose of this therapy is to provide the adolescent with support and therapeutic interventions that will help improve emotional well-being, promote healing, and foster self-awareness. The treatment will incorporate a combination of psychotherapy, music therapy, Humanistic Gestalt approaches, MBCT, and CBT.

2. Voluntary Participation: I understand that participation in therapy is voluntary. The adolescent may choose to discontinue treatment at any time, and I will be consulted if needed for guidance and feedback on the process.

3. Confidentiality: All sessions will be confidential, and any information shared during the therapy process will remain private. However, confidentiality may be broken in the following situations:

   • If there is an immediate risk of harm to the adolescent or others.

   • If there is suspicion of abuse or neglect.

   • If required by law or subpoena.

4. Assessment of Progress: Dr. Patrick will regularly assess the adolescent's progress, and adjustments may be made to the treatment plan as needed. Treatment is individualized, and the use of expressive therapies (such as music and arts) will be integrated throughout the process.

5. Expectations of Participation: I understand that in addition to attending therapy sessions, the adolescent may be given homework assignments or exercises to complete between sessions. These may involve activities such as journaling, reflective writing, music engagement, and family communication exercises. Parent participation and family discussions may also be a part of the process.

6. Parent Involvement: As the adolescent’s parent or guardian, I agree to be involved in the treatment process as appropriate. This may include:

   • Attending parent sessions, if requested.

   • Participating in family therapy and check-ins.

   • Assisting in completing reflective assignments that encourage family dialogue and healing.

7. Risks and Benefits: I acknowledge that psychotherapy and therapeutic interventions, including music therapy and expressive therapies, can bring about both positive change and emotional challenges. The benefits of these therapies include enhanced self-awareness, emotional regulation, and healing. Potential risks may include temporary emotional discomfort as past trauma and difficult feelings are processed.

8. Financial Responsibility: I understand that I am financially responsible for the services provided and will adhere to the payment structure outlined by Dr. Patrick and The Therapy Experience.

Acknowledgment and Consent

I have read and understood the information above regarding the therapeutic services offered by Dr. Alaina Patrick, Founder of The Therapy Experience. I give my consent for the adolescent named above to participate in the therapy program as described.

I also acknowledge that I have been informed of the nature of the treatments and therapies, my rights as a parent/guardian, and the responsibilities involved in this treatment process.

Parent/Guardian Signature: ____________________________

Adolescent’s Signature

Contact Information:

If you have any questions or concerns, please do not hesitate to contact us at:

Phone: 512-850-4844

Email: dralaina@thetherapyexperience.com