Confidentiality and Legal Waiver for Child and Adolescent Holistic Therapy
Mindful Soul Movement, LLC
Alexandra Burkowsky, BSN, MSN
This document outlines the nature of holistic therapy services provided to minors and establishes clear expectations regarding confidentiality, parental involvement, and legal boundaries. As the legal guardian of a child or adolescent entering therapy, it is
essential that you understand and consent to the terms of this agreement.
Confidentiality and the Zone of Privacy
Holistic therapy is most effective when there is a strong, trusting relationship between the practitioner and the child or adolescent client. To support this relationship, it is important that the client has a "zone of privacy"; where they feel safe to speak freely.
Therefore, it is my policy to provide general information about your child’s treatment progress but not to share specific content discussed in session without your child’s consent.
Exceptions to this confidentiality will occur only if there is reason to believe that your child has been or is being abused, is at risk of harming themselves or someone else, or is engaging in behaviors that place them in immediate danger. In such situations, I am legally and ethically required to inform the legal guardian and, when necessary, the appropriate authorities.
This privacy also applies to treatment records. By signing this waiver, you acknowledge and agree to waive your right to access your child’s detailed therapy notes. A written summary of treatment can be provided upon request.
Adolescent-Specific Considerations
Adolescents may disclose sensitive information such as sexual activity, substance use, or high-risk behavior. These matters will remain confidential unless they pose an imminent threat to your child’s safety or the safety of others. I will notify you of any missed appointments or if a referral to another provider is recommended.
Parental Disagreements and Therapeutic Boundaries
If differences arise between parents, or between a parent and the practitioner, I will listen openly and respectfully, and offer my clinical perspective.
You agree that my role is strictly limited to providing holistic therapeutic support for your child and not to serve as an evaluator or legal expert. You further agree not to involve me in any legal dispute, including but not limited to custody, visitation, or other family court matters. This includes not calling me to testify, subpoenaing records, or referring to therapy content in any legal proceedings.
Custody and Parental Consent
Roi Danon holds 100 percent physical custody of the minor child, Aviya Danon. This custodial arrangement was based on a decision made by Aviya at the age of 16, on April 10th, 2025, when she expressed her desire to live full-time with her father.
Upon learning of this decision, her mother, Sivan Danon, verbally agreed to allow Aviya to reside exclusively with Roi Danon.
Therefore, Roi Danon is the sole parent authorized to make decisions related to Aviya’s therapy and will serve as the signing guardian for this waiver. Sivan Danon has expressed her intention not to be involved in any parental or therapeutic decision-making and will not participate in the treatment process.
Acknowledgment and Signature
By signing below, you acknowledge that you have read and understand the terms outlined in this waiver and agree to the conditions of confidentiality, therapeutic boundaries, and legal limitations as stated.