Youth Agreement

Thank you for agreeing to see me as your counselor. I understand that it may not be your choice to be in counseling at this time but I will try to make this experience as pleasant for you as possible while also helping you to make positive changes in your life. My primary goal in our counseling sessions is to help you meet your own positive goals. In order for me to be able to do this, however, I will need your help. I will expect you to do the following in order for us to get the most out of our time:

1) Show up for your sessions and be on time. In fact, it would be a good idea to be here a few minutes early.

2) Be willing to talk about what is going on. Staring contests are a slow way to pass our time.

3) Be honest. Although I love a good story, telling me lies won’t help you any and may just make your time with me longer!

4) Let me know if there is something that you really want or need to talk about during our sessions. I can’t read minds and if you don’t let me know, I’ll probably have us talking about something I find important, even if you don’t think it is.

5) Follow through with any work that we agree on.

In return I will do the following for you:

1) I will keep what you tell me confidential (secret) with the following exceptions by law:

a) I have good reason to believe that you may harm or attempt to kill yourself. In that case I may have to let a parent/guardian and possibly a police officer know so that we can work together to ensure your safety.

b) I have good reason to believe that someone who is or was responsible for your care abused you in some way or abused another child, disabled person, or elderly person that they were caring for in which case I will need to inform the Department of Children and Family Services.

c) I receive a court order for your records.

In any of these cases I will let you know that I have to give certain information and to whom I will be giving it to. There may be times which you tell me something that I believe it is important for your parents to know, but I still will not be able to tell them. What I may do, is encourage you to tell your parents with my help. If you decide not to, I will not try to force you and again, I will NOT tell them myself. At times your parent/guardian may want an update on your progress in treatment. With your help, I will give them general progress reports such as you are opening up and talking to me, you seem to be making improvements, or we figured out what we need to work on and are starting to do so, without telling them what we are talking about. If you wish to tell your parents what we are talking about, you may do so, however.

2) I will be honest with you and will help you to the best of my ability.

3) You will have a say in your treatment by being able to tell me your goals for therapy as well as having a say in the ways in which we work towards those goals.

Your Full Name

First Name

Last Name

My ABC Counselor:

I understand that it is my responsibility to be honest in my sessions with my counselor. I also understand what confidentiality is and what may cause my counselor to bypass that agreement. I have been explained what is expected of me in treatment and what I can expect from my counselor and agree to all of these terms. I was given an opportunity to ask all questions I have about treatment and understand I can ask any other questions I think of later.

Yes, I understand.

Youth E-Signature

Ages 13-18

First Name

Last Name