Statement of Informed Consent

I affirm that my child is 14 to 17 years old and has been
referred for counseling by a school counselor or administrator!

I understand that therapy via the Internet is an experimental modality and there is not yet sufficient empirical evidence to show that it works. There is, however, evidence that traditional forms of face-to-face therapy DO work. Therefore, Choose 2 Change has advised me that I should seek out a qualified therapist in my area if that is a viable option for me.

I have chosen this mode of therapy for my child because more traditional face-to-face therapy is not appropriate for my child for reasons of mobility limitations, geographic isolation, child care availability, work situations or because there are circumstances that make communication via keyboard preferable to verbal communications.

I understand that, for all legal and regulatory purposes, the services provided via this method of therapy are considered to be provided in the United States of America. I further understand that the therapist that my child will be working with is either a Licensed Marriage & Family Therapist or a Licensed Clinical Social Worker and is subject only to the laws and regulations of the state and country in which he or she is licensed. All Choose 2 Change counselors subscribe to the Code of Ethics of the American Association of Marriage and Family Therapy and/or the American Psychological Associations and are subject to sanction by the Association(s) for violations. I also understand that, while my counselor may not be a member of the organization, he or she subscribes to the code of ethics for online practices of the National Board of Certified Counselors.

I hereby certify that I give my consent according to the laws of my home state, province, or country for my child to participate in the Choose 2 Change program. I understand that, in keeping with US Supreme Court decisions, my child's counselor is required to violate my child's confidentiality and make appropriate notifications if he or she believes that my child may intend to hurt themself or another person or that my child is involved in child abuse, child neglect, or elder abuse.

I understand that it is unlikely that my insurance provider or national health care plan will reimburse me for the cost of this therapy and I chose to be a "private payer" and pursue any potential reimbursements on my own.

I understand that the fees I will be charged for this service include a one-time registration fee of US$ 125.00 (non-refundable) and US$ 75 per counseling session.

If you give your consent for your child to work with one of our counselors, please click on I AGREE to continue the registration process.

If you are not willing to give your consent for your child to work with one of our counselors, please click on I DO NOT AGREE and you will be redirected back to the Home page.

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