Capella University Ethical Challenges in Mental Health Services Discussion

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Ethical Challenges in Mental Health Services to Children
and Families
m
Gerald P. Koocher
Simmons College
Mental health practitioners working with children and families must
attend to several ethical concerns that do not typically come into play
with adult clients. The challenges for practitioners usually involve
attention to four subsets of concerns that all begin with the letter c:
competence, consent, confidentiality, and competing interests. Using
the 4-C model, this article focuses on ethical aspects of practitioner
competence, consent and assent, confidentiality, and the incongruence of interests that occurs when different people organize and set
goals for psychological services. After explicating these issues, I
provide recommendations for addressing them in the course of
clinical practice. & 2008 Wiley Periodicals, Inc. J Clin Psychol:In
Session 64: 601–612, 2008.
Keywords: competence; consent; confidentiality; conflict of interests;
ethics; psychotherapy
Providing mental health services to children and families has many rewards, not the
least of which involves improving the quality of life for vulnerable young people and
those who care for them. Working in this arena also demands particular awareness
of many essential nuances in attending to the rights of those we serve and our special
responsibilities to them (Dishion & Stormshak, 2007; Koocher, 1995, 2003; Rae &
Fournier, 1999; Ratner, 2002; Sori, 2006). One useful model for focusing on these
matters involves four cs: competence, consent, confidentiality, and competing
interests. Each of these cs will help to guide a thoughtful route through the ethical
challenges that routinely demand consideration in providing mental health services
to children.
Correspondence concerning this article should be addressed to: Gerald P. Koocher, School for Health
Studies, Simmons College, 300 The Fenway, Boston, MA 02115; e-mail: Koocher@simmons.edu
JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 64(5), 601–612 (2008) & 2008 Wiley Periodicals, Inc
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20476
Competence
Practitioner Competence
Competence generally refers to the quality of having adequate or better ability to
perform some task physically, intellectually, emotionally, or otherwise (see Wise, this
issue). This definition of competence ties closely to specific functions, so one will
almost always see the preposition to accompany its use. For example, one may have
excellent competence to manage one’s investments and financial affairs while
demonstrating inadequate competence in plumbing or parenting skills.
What constitutes adequate competence to treat children and adolescents in
psychotherapy? Licensing statutes offer little guidance, and most regulatory
authorities recognize an entry to practice threshold without specifying particular
skills. Most employers will certainly look for appropriate education and experience
when making hiring decisions, but private practitioners face minimal regulation in
determining their own domains of expertise. Unless something goes wrong and
someone complains to a licensing board or an ethics committee, practitioners’ selfassessments or educative comments from concerned, aware colleagues constitute the
only forces regulating the assessment of their practitioner competence in most
situations.
Occasionally practitioners stray into the arena of child and adolescent practice
without adequate preparation. For example, some clinicians who practice ‘‘couple
and marital therapy’’ or ‘‘personal coaching’’ seem all too willing to offer parenting
advice or child guidance despite lacking adequate knowledge of child development,
child psychopathology, or child/adolescent psychotherapy. Similarly, one occasionally finds individuals with degrees in ‘‘applied developmental psychology’’ offering
parents advice of a clinical nature without adequate preparation (Koocher, 1990).
Decisional Competence in Children and Adolescents
As psychotherapists, we tend to think of competence along continua such as
beginner, intermediate, or expert, and that perspective meshes well with both
educational competence models (as described earlier). That same model applies well
when we consider how children at various ages might have varying degrees of
personal competence to make decisions. In the eyes of the law, however, competence
becomes quite specific and tightly regulated. For example, assessment of legal
competence may focus on the mental capacity of an individual to participate in legal
proceedings, manage personal finances, adequately parent their children, or even
possess the statutory authority to make binding decisions. Adult defendants who
lack sufficient competence may escape criminal prosecution, find themselves deemed
incompetent to testify, or have contracts they signed voided. Children present some
unique problems in this regard.
In legal parlance, one must distinguish between de facto (i.e., actual) and de jure
(under the law) incompetence (Koocher & Keith-Spiegel, 1990). The legal system
presumes adults to be competent, but considers people who have not yet reached the
age of legal majority incompetent de jure. Minors therefore lack many rights of adult
citizens (e.g., voting, making legal contracts). In most situations, minors cannot
legally make decisions about their health and privacy. Some states provide
mechanisms to have minors declared ‘‘mature’’ or ‘‘emancipated,’’ and thus qualify
for some legal prerogatives. Many states also allow minors to consent to treatment in
specific circumstances without parental consent, if deemed in the public interest.
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Such situations may include the case of minors who believe they may have a sexually
transmitted disease, a substance abuse problem, or may be pregnant.
As a result, the decision to seek, set goals during, or terminate psychotherapy
typically does not rest in the hands of child and adolescent clients. As discussed later,
this fact can raise particular problems regarding consent to treatment, confidentiality, and potential conflicts of interest among youthful clients, their parents, and
other authority figures. This situation may become paradoxical at times when bright,
articulate children clearly have the actual cognitive and emotional capacity to
express well-informed thoughtful preferences and decisions, but disagree with those
holding legal authority.
Consider the following three case examples. A psychotherapist trained to work
with adult clients as individuals and couples accepts for treatment a family with
children ages 9, 12, and 15 years. Another psychotherapist has lost two children in a
tragic accident 6 months ago and cannot keep his thoughts from focusing on his own
loss when he hears about interactions involving children of the same age as his
deceased family members. Finally, a third psychotherapist listens to parents, proud
of their careers as musicians, describe their anger and frustrations regarding their
child’s reluctance to practice the French horn after they have spent a considerable
amount of money on music lessons.
In the first case, we may have a psychotherapist blind to his or her lack of
professional competence. Without some education and training relevant to both
child and family therapy, such psychotherapists place the clients at risk for
ineffective services or actual harm by practicing beyond their areas of competence. In
the second case, the psychotherapist’s emotional competence is challenged by the
tragic events in his own life. To the extent that he continues to practice while such
personal issues intrude, he too places clients at risk of receiving ineffective services or
harm. In the third case, the psychotherapist must consider the degree to which the
parents’ goals and their child’s goals fail to align. Have they given credible
consideration to the possibility that the child may not aspire to follow them in
musical careers? Does the child actually need psychotherapy, or do the parents need
help at exploring their own motives and needs?
Consent
Children rarely seek psychotherapy of their own accord. Usually one or more adult
authority figures (e.g., parents, school personnel, juvenile court officers) have
decided that the child’s behavior should change in some ways and hope that the
therapist can assist in bringing that about. When youthful clients lack the legal
capability to give consent, permission (i.e., proxy consent) must come from parents
or legal guardians. As psychotherapists, however, we also have a responsibility to
consider the best interests of our vulnerable clients.
Suppose that a school principal demands that parents seek stimulant medication
for a child who cannot sit still in class (Bor, Ebner-Landy, Gill, & Brace, 2002;
Breeding, 2001; Lewis & Porter, 2004; Ratner, 2002). Imagine a parent who seeks
psychotherapy for his child who has stated preferences or made reasonable choices
to which the parent objects: ‘‘He wants to be an auto mechanic instead of a
neurosurgeon like his father.’’ ‘‘She wants to date a (choose any ethnic, racial, or
religious group) boy! He’s not our kind.’’ Consider the start of a family therapy
session when the therapist asks an adolescent and her parents about their view of the
problems in the family, and the teen, pointing at her parents, replies, ‘‘I have two
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problems: him and her!’’ Each of these situations presents the psychotherapist with
goal-setting problems (Koocher, 1995, 2003). One must certainly assess all clients
and perceived problems carefully before planning treatment, but many different
voices may chime in with proposed (or demanded) goals for therapeutic work with
child and adolescent clients.
Most parents or guardians will have their children’s best interests at heart and will
make treatment decisions based on caring, well-informed reasoning. At times,
however, parents’ may disagree with each other or with their children on the best
course of action. In addition, parents sometimes do not recognize their own biases or
respond uncritically to the assertions of other authority figures in their children’s
lives. As discussed in the section on conflicting interests a few pages hence, the
clinician can perform a critical leveling role in such situations by conducting a
careful evaluation and framing recommendations for treatment strategies and goals
based on data obtained from all parties. Ideally, this will involve engaging the child
or adolescent client in a manner consistent with his or her developmental level. At
times, this may mean presenting family members with recommendations or advice
that they will find difficult. At other times, it may require advocacy with school or
community authorities. Always, the key involves focusing on the needs and wellbeing of the client with attention to the most vulnerable party when the focus of
treatment falls on the family unit.
Confidentiality
Commentaries on confidentiality in child therapy (e.g., Gates & Arons, 2000;
Koocher & Keith-Spiegel, 1990; McCurdy & Murray, 2003; Moore, 1994; Rae &
Fournier, 1999) have illustrated the range and complexity of the subtleties in
respecting the privacy of children. Can a 4- or 5-year-old conceptualize confidentiality or believe that adults keep secrets from one another? Can an adolescent use
therapy effectively without assurance of confidentiality? Do parents have the right to
expect access to treatment they pay for or alerts if their child poses a risk to self or
others? Do parents, therapists, and minors even agree on what constitutes a risk
(e.g., smoking tobacco, marijuana, and/or crack cocaine; watching ‘‘R-rated
movies;’’ petting or more intense sexual activity)? While no simple guide can
address every situation, ethical considerations require an effort to clarify
expectations of all parties at the outset of the professional relationship.
Necessary Secrets
One can certainly tailor scripts to the developmental level of the client, but ideally
the discussion occurs together with the decision-making authority (i.e., child and
parents or guardian together) before actual treatment sessions begin (Sori, 2006;
Sparta & Koocher, 2006). The discussion should include the notion that successful
therapeutic alliances depend on some degree of mutual trust established in part
through privacy of sensitive content (Harbour, 2004). While recognizing the legal
authority of the parents or guardian and their legitimate interests in the well-being
and progress of the child, one can seek a mutually acceptable understanding of
confidentiality to which all parties can agree. This will generally not prove difficult
for younger children.
In the case of adolescents, one would certainly want to comment that teenagers
often want to talk about private matters such as peer conflicts, school problems,
smoking, alcohol, sex, and other matters that they might prefer not to raise
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simultaneously with their parents. By coming to a mutual understanding on such
necessary secrets and points at which disclosures may prove warranted (e.g., threats
of harm to self or others), the clinician can negotiate acceptable limits with all parties
at the outset of their work together. As part of the process, therapists will need to
think through what sorts of behaviors rise to the level of warranting parental
disclosure.
For example, imagine that during a psychotherapy session a 15-year-old client
reports her intention to engage in sexual activity with a high-school classmate a few
days hence. As her psychotherapist, you inquire and conclude that the young woman
understands safe-sex practices and does not feel coerced into the behavior. Does this
information constitute a confidence that you should keep and not disclose to her
parents? Suppose that the intended partner is 18 years old, 25 years old, or 35 years
old. Consider whether the shifting age alters your opinion, and if so, why. Now
suppose your client reports that she plans to exchange sexual favors for money or
illicit drugs. The therapist’s mental calculus will need to include a multitude of
considerations. Does the planned activity constitute reasonable, normative,
adolescent behavior? What cultural considerations of both therapist and client
establish the norms? What risks of harm does the client face? Why has she told her
therapist about this in advance (i.e., does she hope the therapist will take some action
to dissuade her?)? What steps can the therapist take that will most effectively benefit
the client and advance treatment? What duties does the therapist owe to the client’s
parents?
Of course, no amount of planning will cover every possible subsequent event. Even
the most creative therapists will run into unanticipated behavioral adventures with
their adolescent clients. Having pledged unconditional respect for their child’s
confidentiality at the outset of treatment, parents may change their minds and
demand information from the therapist or access to their child’s records with full
legal authority under the Health Insurance Portability and Accountability Act of
1996. In the final analysis, clinicians must take guidance from their considered
understanding of their clients’ best interests and applicable legal standards.
Mandated Reporting
The most significant legal standard regarding breaches of confidentiality in the
treatment of children and adolescents involves statutory mandates to report
suspected abuse or neglect (Kalichman, 1999; Koocher & Keith-Spiegel, 2008;
McCurdy & Murray, 2003). Such statutes typically require that certain designated
professionals, including all those commonly involved in the care, education, and
oversight of children (e.g., educators, nurses, physicians, psychologists, and social
workers), notify governmental authorities if they have ‘‘reason to believe’’ or
‘‘reasonable suspicion’’ (depending on statutory language) that a person under the
age of majority has suffered abuse or neglect. Such statutes originate with the
doctrine of parens patraie, under which the state asserts authority to care for
vulnerable citizens.
Some psychotherapists worry that reporting based on a suspicion may lead to
family destabilization, forced engagement with an overwhelmed state child welfare
system, treatment disruption, and other undesirable outcomes. At the same time,
psychotherapists usually have no authority or realistic ability to investigate
suspicions of abuse. By obeying the law and filing the mandated report, the
clinician acquires a degree of legal protection (e.g., a good-faith filing protects the
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reporter from defamation suits if the abuse/neglect suspicions prove unfounded). By
not reporting, the practitioner risks continuation of the abuse and penalties for
nonreporting. Interestingly, some surveys have demonstrated group differences in
perceptions of the need to report in various contexts (Kalichman, 1999). One survey,
for example, demonstrated that female psychotherapists may have a lower reporting
threshold than do their male counterparts when faced with ambiguous circumstances
(Finlayson & Koocher, 1991).
The key to ethical conduct in such situations involves knowing the applicable laws
in one’s practice jurisdiction, informing clients of this limitation of confidentiality at
the start of the professional relationship, and understanding the behavioral signs of
abuse or neglect. These principles link back to the basic concepts of competence (i.e.,
knowing the applicable laws and understanding how to diagnose potential abuse/
neglect) and consent (i.e., informing clients of limits on confidentiality) described
earlier.
Competing Interests
All families include people whose interests do not align in perfect congruence. One
would hope that most parents have the best interests of their children at heart, but
that does not always occur. In addition, many people caught up in their own
emotional distress or otherwise unable to take an alternative perspective may fail to
recognize that their behaviors will not benefit or may actually cause harm to their
children. Psychotherapy with children and adolescents constitutes a kind of a forced
multiple relationship. The clinician typically has an identified client with a plethora
of interested others who may have pressed for enrolling the child in psychotherapy,
who may have responsibility to pay the therapist’s bill, who may have outcome goals
quite different from the child, and who may or may not have legal decision-making
authority.
Such concerns arose earlier under the heading of consent, but one also must consider
the ubiquitous competing interests. Therapists must carefully consider to whom they
owe which duties, and explicate these carefully. Here are some typical examples.
Parents bring a 10-year-old to treatment at the behest of school authorities,
concerned about the child’s behavior. The parents ask the psychologist to
help solve the school behavior problem, but specify strict limits on
communicating with the school.
While treating a 4-year-old with toileting problems, the therapist works
closely with the parent. It soon becomes clear that the parent has significant
depression and seems to want the therapist to work on her disorder as well
as the toileting problems.
While working with a 14-year-old eating-disordered client, the clinician
becomes aware that the parents’ marriage has become increasingly fragile.
The therapist sees a separation and possibly divorce on the horizon, and
anticipates that the child may become the focus of a custody dispute.
The school contact case may prove the easiest to resolve. The therapist can engage
in ongoing discussion with the parents reviewing what information to share with the
school personnel on a need-to-know basis. By establishing a clear alliance with the
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child and parents, the therapist can hopefully encourage them to allow disclosure of
whatever information might become necessary to bring about positive change. In
some situations, however, the therapist’s role may have additional complications
(e.g., as a person on the school’s payroll). Any such conflicts of interest should be
made known before service begins, along with a discussion about managing any
tensions that may arise.
Performing effectively as a child or adolescent psychotherapist almost always
involves contact and engagement with parents or guardians (Dishion & Stormshak,
2007). At times, the child’s ‘‘problem’’ may well reflect or flow as a response to
parental psychopathology. Particularly when working with younger children, a family
session or parental guidance becomes an essential part of the therapeutic process. Even
if the child’s therapist has the competence to treat a parent’s individual psychological
problems and even if a parent requests such individual treatment, doing so will prove
ethically challenging. The best course of action would involve discussing the concept of
the parent as a client for a limited purpose at the outset of treatment. A
psychotherapist can explain that his or her work may involve talking with parents
about their feelings and concerns as these bear on the treatment of child, but note that
he or she would refer them to a therapist of their own should they need help with
individual or couple distress. Sample text appears at the end of this article.
When dealing with children from families who demonstrate high levels of parental
tension or open conflict, psychotherapists should anticipate that the couple’s
relationship may possibly dissolve and result in a custody dispute (Southern, Smith,
& Oliver, 2005). The next two sections discuss some specific recommendations for
clinical management of such families, with an eye towards therapist behaviors that
can optimize the best interests of the child. The key point to be made here is that the
therapist must remain attuned to the stability of the family system in which their
patient resides and plan accordingly.
Separated Records
When setting up clinical records for child clients, therapists will want to keep
separate notes regarding contacts with the child and contacts with others. The
records or psychotherapy notes of the child should remain separate from notes of
family sessions or notes of meetings with one or both parents. This practice becomes
particularly important when dealing with hard copy (as opposed to electronic) files.
For example, when authorized to release the child’s records, one should not
include material from an individual meeting with one of the child’s parents. If all
notes in the therapist’s file flow continuously in sequence from page to page,
redacting material can prove time consuming and error prone. Suppose that a
therapist who treats a child routinely meets individually with the child’s divorced
parents. Should one parent seek a copy of the child’s records, the notes from
meetings with the other parent cannot ethically be included. Keeping separate files or
file sections for each party affords the simplest way to manage such problems. When
working at an agency or in a group practice, psychotherapists should educate
support staff who file records or respond to requests for record releases to attend
carefully to such matters.
Anticipating Litigation
At this point, readers have no doubt begun to think of what might happen if they
find themselves embroiled in a dispute over the custody of a child they have treated.
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Precautionary steps can minimize the risk that an ethical violation will grow out of
the therapist’s role.
When agreeing to treat a child whose parents have separated or divorced, seek the
consent of both parents to treat the child. If the parent bringing the child for
treatment hesitates about allowing the other parent to know of and consent to
treatment, do not agree to take on the case (If told that the other parent’s
whereabouts are unknown, that their parental rights have been terminated, that a
restraining order is in place, or that they are incarcerated, then document those
assertions in the case file.)
If divorce seems probable or possible, ask both parents to agree in writing that
they will not seek to call the child’s therapist as a witness or seek to introduce the
child’s treatment records as evidence. Sample text for a consent form appears in the
example at the end of this article.
If you are called as a witness or if an attempt is made to obtain the child’s
psychotherapy records for use in reaching a custody decision, then consider asking
the judge to appoint a guardian ad litem to oversee the child’s privacy or exercise the
child’s privilege (Coates, Deutsch, Starnes, Sullivan, & Sydlik, 2004; Levick, 2000). If
you must testify, limit your comments to treatment of the child while making it clear
to the court that you have not conducted a custody evaluation and will not make
custody recommendations.
Psychotherapists who find themselves in ethical complaint situations in the context
of custody disputes have generally allowed themselves to step out of the therapy role
to testify as evaluators or to make recommendations in the absence of an evaluation
(Oberlander, 1995; Weithorn, 2006). Alternatively, some complaints result when one
parent objects to the other’s enrolling the child in psychotherapy. The best
suggestion a therapist can offer a distressed parent who believes that the child’s
psychological status demands consideration in the custody dispute is to seek
appointment of an independent evaluator. Attending to the points outlined earlier
will generally prevent significant ethical problems.
Practitioners also should remain alert to potential involvement in litigation with
certain types of referrals. In particular, when a parent brings a child for treatment
following some traumatic event (e.g., automobile accident or dog bite) or advises
that an attorney recommended treatment, the clinician should anticipate that he or
she may at some point receive a request for records or a report regarding emotional
damages that the child may have suffered. The primary concern for the clinician in
such cases involves the potential request for a therapist to offer evaluative comments
in litigation. Perhaps the child did suffer some psychological trauma as a result of the
incident, and perhaps the psychotherapist will be in a position to offer
documentation that may prove useful to the client’s attorney; however, in some
cases, therapists may not find themselves ethically able to support the claims as the
attorney had hoped. Consider the following scenario:
Suppose that a parent presents a 10-year-old boy for psychotherapy after
the child received a nasty bite from a neighbor’s dog. The parents mention
to the therapist that they have hired an attorney and plan to sue the
neighbor. By the third or fourth session, the psychotherapist has completed
a history and met with the child a few times. The child has a history of
significant behavior problems dating back to kindergarten, when he was
expelled for hitting other children. The parents and school have noted a
persistent history of fire setting and episodic cruelty to animals in the
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neighborhood. The boy also described ‘‘defending himself’’ with a metal
poker he had heated in a back yard ‘‘campfire’’ and carried to the fenced-in
yard containing the dog three houses away. It becomes increasingly clear
that the very troubled child had gone to some lengths to provoke the dog
that bit him. The parents and attorney would like the therapist to prepare a
report that ‘‘only addresses the current injury caused by the vicious dog that
poses a threat to the neighborhood.’’
Hopefully, psychotherapists confronted with such situations would retain their
integrity and decline to report on anything less than the complete situation; however,
doing so may anger the parents and disrupt the treatment of a troubled child. The
more appropriate stance would have the therapist discuss the situation and
impressions openly and candidly with the family and the attorney, but decline to
issue a selectively biased report while stressing the child’s need for treatment.
Practice Recommendations
In considering how to address competence, consent, confidentiality, and competing
interests to advance ethical practice in psychotherapy with children and adolescents,
clinicians will want to consider several fundamental steps.
* Treating children and adolescents differs significantly from the treatment of
adults and couples. These differences require that those who would perform such
treatment obtain appropriate education and training to establish and maintain
their competence.
* Children’s capacities to make decisions, including those related to setting
treatment goals, vary as a function of their developmental level and legal
standards. Psychotherapists should take these differences into account when
obtaining consent, permission, and assent during treatment.
* Legal standards generally allow children to keep secrets from their parents only to
the degree that the parents permit. Psychotherapists should consult with parents
and children at the outset of a treatment relationship to establish the parameters
of confidentiality that will apply.
* Mandated reporting of suspecting child abuse/neglect applies across the United
States and Canada. Psychotherapists should remain familiar with the statutes and
policies that apply in their jurisdictions, and discuss these with families at the
outset of the treatment relationship.
* The values, needs, and motives of family members will necessarily differ and even
conflict at times. Psychotherapists must recognize that such competing interests
present conflicts that require thoughtful attempts at reconciliation.
* Child psychotherapists routinely engage normal parental feedback and guidance.
In such activities, parents hold a type of client status, but for a specific and limited
purpose related to their child’s care. The child’s therapist should avoid acting as a
therapist for a parent, and should help define his or her role clearly, making
referrals for such parents as needed.
* Psychotherapists should keep records in a manner that makes the notes from the
child’s sessions easy to separate from notes taken in meetings with parents or
other family members. Keeping notes in separate files or documents facilitates
honoring requests by individual parties for records.
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* Child psychotherapists should remain aware of situations that may result in
litigation, particularly child custody disputes. In such situations, therapists must
take care to retain professional integrity and to avoid giving testimony beyond the
scope of their work. Therapists also must recognize that providing evidence in
litigation involving child clients has the potential to disrupt relationships and
compromise the therapeutic process.
Sample Consent Form for Use in Child Treatment
Many examples of psychotherapy consent forms exist (e.g., Clemens, 2002; Snyder &
Barnett, 2006; http://kspope.com/consent/index.php]forms). Most of these forms
omit mention of key issues related to treatment of children and adolescents. As
discussed earlier, psychotherapists may want to consider adding text from the
following sample paragraphs to their psychotherapy consent forms, as warranted.
Who Is My Patient?
Consultation with parents (or guardians) is an essential part of child/adolescent
psychotherapy, and I will have a professional relationship with all of you. From time
to time, parents will voice personal concerns in the course of consulting with me as
their child’s therapist. I will gladly listen to these concerns and assist to the extent I
can; however, my primary role is as therapist to your daughter/son. If your own
difficulties suggest a need for professional help, I will refer you to an appropriate
colleague or agency.
Confidentiality
Psychotherapy works best when clients can trust their therapists to treat sensitive
concerns confidentially. Parents (or guardians) also have a legitimate need to know
how psychotherapy with their son/daughter is progressing. I will ask you to agree to
respect the privacy of your child’s treatment records, but will plan to hold regular
family or parent meetings to keep you posted on your child’s progress. I will contact
you immediately if I believe that your child’s behavior constitutes a risk to herself/
himself or others. We should speak about any concerns you may have regarding
specific types of risky behavior, as a family, before treatment begins.
Legal Proceedings
Forcing discussion of a child’s psychotherapy in court or legal proceedings can
undermine the therapeutic relationship and prove harmful to the child. As I begin
treating your child in psychotherapy, we all agree that my work will not involve any
evaluation relevant to legal matters. By signing this form, you agree that you will not
call me as a witness to testify in any child custody matter or other legal proceeding.
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