Agreement for Placing a Child

Agreement between the child, the parents or custodian or placing agency and the therapeutic milieu :

1- the child is placed according to her/his will, with the goal to cure her/him from the disturbances or illness s/he is suffering from.

2- the child may stay at this program as long as s/he wants it : the child will be removed only if s/he wants it excepted if s/he appears to be unmanageable about a risk of harm to others or to her/himself.

3- the parents or custodian accept that it is the child's right to change and to cure.

4- the parents or custodian accept that the child's wishes for all that regard her/himself have priority upon all other persons' wishes, including taking or not medications.

5- relationships and visits with the child's relatives happen only when, how long and in the way the child wishes.

6- parents or custodian certify that they have read and understood the therapeutic milieu guidelines here presented, and that they will not try to interfere with the implementations of these rules as they are conceived to improve the child's mental and physical health and safety.

7- parents or custodian allow emergency medical care for the child.

8- the therapeutic milieu team engages to implement all the features described in the present guidelines.

9- the therapeutic milieu team engages to implement the confidentiality rules:
- no data about the child and her/his parents will be communicated to outsiders except to local or state authorities
- the child's progress data will be communicated to parents or custodian only with the child's consent.

10- parents, relatives or custodian acknowledge that if in the course of therapy the child discloses having been a victim of abuse (emotional, physical and/or sexual), the therapeutic milieu representative will perform our duty to inform authorities according to law.

Done sincerely on (date and location) :

Name and signature of placed child :

Name and signature of parents or custodian
or of placing agency representative :

Name and signature of the therapeutic milieu representative :

rev. 2013