Treatment of Minors

Rula offers therapeutic services to minors - defined as any child or adolescent who is between the ages of 5 and 17 who is not legally responsible for themselves. This article offers guidance and best practice considerations for providing ethical, quality treatment to clients ages 5-17 at Rula.

Who consents to a minor's treatment?

We know there are varying state laws regarding minors' ability to consent to mental health and/or substance use treatment. While some states recognize that certain minors can seek treatment without parental consent, it is the practice of Rula to not to accept minors into treatment without consent from a parent or legal guardian.

The consenting parent/guardian’s legal responsibility is to ensure that the appropriate parties have agreed for a minor to receive treatment at Rula. Therefore, in our registration process we specify that the parent/guardian must disclose if a custody arrangement is present. Rula collects informed consent from the parent/guardian before the first appointment. You can find evidence of this information in the Documents folder for the client. If there are questions about state specific laws regarding consent that are not addressed specifically in this article, the Rula Compliance Officer should be consulted at privacy@rula.com

Consent requirements based on family structure

Biological / Adoptive Family

Generally, in an intact family (two biological/adopted parents) only one parent needs to provide consent prior to or at the minor’s first session. It is recommended that the therapist seek the consent of the other parent and ensure that the other parent is aware of treatment; however, it is not required. Both parents can attend individual and/or family therapy sessions of the minor.

Separated / Divorced Family

Reasonable steps should be taken to determine which parent has the legal authority to consent to mental health and/or substance use treatment of the minor. It is the responsibility of the parent entering the minor into treatment to notify the other parent of the treatment. Rula includes the following language during the consent process, as determined by our legal counsel: if parents are divorced, parents need to follow custodial arrangements on who is permitted to consent to medical care for the minor. The parent has attested to this statement at the time of consent, prior to the appointment.

Consent is usually determined in the divorce decree or custody court paperwork. Many times court paperwork does not specify “mental health” or “substance use treatment,” but it is assumed under “medical treatment.”

If the parents share joint legal custody, usually they share the right to make healthcare decisions for the minor. Either parent alone may consent to the minor’s treatment (unless specified as above). In rare cases, the custody court order may specify that both parents must consent to treatment.

If one parent has sole custody, they alone have the right to make healthcare decisions for the minor and can consent to treatment without the other parent’s consent.

If the provider learns through the course of treatment or otherwise that the non-medical decision making parent consented to treatment, the provider will pause treatment until the parent who has medical decision making authority can consent to continued treatment.

Other Legal Guardians

At this time, non-biological parents (stepparents) may not consent to treatment of a minor unless they have legally adopted the minor, or become the minor’s legal guardian, or are acting in loco parentis. If permitted by the client and biological parent, the non-biological parent may attend the client’s individual or family therapy sessions.

Foster parents, in most cases, are not considered legal guardians of a minor. However, they are responsible for the health, wellness, and care of the minors in their custody. Foster parents may have the legal right to seek treatment for the minor; however, this should be confirmed via court order paperwork and/or seeking permission from the state Department of Human Services.

Other Situations

Emancipated minors may seek and consent to treatment as long as they provide court documentation of their emancipation prior to or during the first scheduled session. Other types of minors may consent to their own treatment in special circumstances. Any special circumstances that arise need to be addressed with the Head of Clinical Care.

Legal Guardianship

A legal guardian has the same authority to consent to medical treatment for a minor as a parent would have. A provider would need to obtain documentation (court paperwork) that identifies the legal guardian of the minor and verify the identified legal guardian is consenting to the minor’s treatment.

Parents/Guardian Involvement in the Treatment of Minors

For minors between the age of 5-12, we require the consenting parent/guardian to be present at the first appointment (Initial Assessment) to confirm medical decision making authority. While Rula has notified minor parents/guardians of this requirement, therapists should consider contacting the parent/guardian of a minor client prior to a scheduled appointment to inform them of this expectation.If a parent/guardian is not present for the first visit with a child, providers should:

Ask the child if their parent/guardian is present in the home and able to join;
If a parent/guardian is not able to join, end the session with the child and Contact the parent/guardian to see if they are able to join the session within the next 10 minutes.
If yes, you may continue (90791 sessions are a minimum of 16 minutes). If not, a no-show fee may be applied.

For adolescents ages 13-17, It is recommended and considered best practice to have the parent/guardian present during the first session, although this is not required. It is the expectation that parents/guardians and families be involved in the minor’s treatment unless otherwise contraindicated. Families of clients are collaborative partners in all aspects of planning, development, implementation, and evaluation of the minor’s behavioral health treatment.

Confidentiality

A therapist's most important ethical duty when treating minors is to discuss and address confidentiality concerns with the parent(s) and the minor. The right to confidentiality in treatment sessions is often connected to the right to consent. Therefore, therapists should discuss with the parent and the minor regarding privacy and limits of confidentiality during the first session and periodically throughout treatment.

Minor Assent

Obtaining a minor's assent (typically conducted in the first session) is to inform them of what will happen during therapy sessions and what information may need to be shared with the minor's parents during treatment.

If you wish to obtain assent, you can use an Assent form to guide this conversation, which can be found as a web link in the EHR. You can also use this minor/adolescent assent and parent/guardian agreement and email it or share it in the chat feature of the telehealth visit. If you use this process, please document this in the initial assessment.

Missed Appointments with Minors

The parent or parent(s) or legal guardian who consented to the minor's treatment should be notified by the therapist of the minor's missed appointment, and should be notified they will be responsible for payment of the no-show fee.

Medical Records Access

Generally, HIPAA offers no protection to minors and requires healthcare providers to release a minor patient’s medical records to the child’s parent or guardian upon request. The Privacy Rule generally allows a parent to have access to the medical records about his or her child, as his or her minor child's personal representative when such access is not inconsistent with State or other law.

Unless a biological parent’s rights have been terminated or there is information in the minor client’s record that could reasonably be harmful to the minor child if the information was released, both biological parents will have the right to access the minor client’s medical records regardless of who signed consent for the minor.

Anyone who is not the legal guardian or biological parent of the minor is not permitted access to the minor’s medical records and is not to be given information regarding the minor’s treatment, unless an authorization form is signed by the parent or legal guardian. If a minor is in foster care, the State Department of Human Services is the identified legal guardian of the minor and can have access to the minor’s medical record.