CL1. Confidentiality & Consent

Respecting privacy, consent, and assent
"I’m not here to be right. I’m here to get it right." — Brené Brown

Policy Purpose

This policy ensures that confidentiality, informed consent, and child assent are consistently upheld across Trust Children and ReadyStepGrow. It protects the privacy of children and families, supports ethical and professional practice, and ensures compliance with legal and funder requirements. It also provides guidance on the safe and appropriate use of AI tools within the service.

Policy Statement

All staff, contractors, and therapy assistants must maintain strict confidentiality in all aspects of their work. Families engage in informed consent at the start of and throughout their relationship with the service, and children are supported to give assent in developmentally appropriate ways. Confidentiality and consent are essential to safe, respectful, and values-led practice.

The use of AI tools is permitted only when confidentiality is fully protected. AI use must align with professional standards, funder requirements, and family trust, and never compromise the rights or privacy of children and families.

Policy Details

Confidentiality Standards

Clinical Information

• Clinical notes and therapy plans must remain professional, impartial, and child-focused.
• Children are identified by initials in email communication and sensitive information must be transmitted securely.
• Non-clinical matters (administration, funding, legal correspondence) must be recorded in service records, not clinical documentation.

Information Sharing

• Information must only be shared with consent from parents/carers, unless required by law (e.g. child protection, court order, subpoena).
• When information is shared with external providers, it must be accurate, necessary, and aligned with the child’s goals.
• Confidential information must never be discussed in public or informal settings.

Use of Artificial Intelligence (AI)

• AI tools may only be used for administrative or drafting purposes where no identifiable client data is included.
• If AI is used to support clinical documentation or resource preparation, all outputs must be reviewed, edited, and approved by the responsible clinician.
• Staff must never upload identifiable or sensitive client information into external AI platforms.
• The clinician (or staff member using the tool) remains fully accountable for the accuracy, appropriateness, and confidentiality of all outputs.

Templates and Practical Guidance

• Role-specific instructions for the safe use of AI (e.g. how to de-identify information, where AI drafting may be used, and required review steps) are embedded within clinical templates such as therapy plan and report templates.
• Staff must follow these instructions in addition to this policy. Templates provide practical “how-to” directions, while this policy establishes overarching principles and accountability requirements.

Consent & Assent Standards

Informed Consent

• Parents/carers must provide informed consent before assessment, therapy, or information sharing.
• Consent includes an explanation of purpose, risks, benefits, and alternatives.
• Consent must be documented in service agreements, intake forms, or clinical notes.

Child Assent

• Children are invited to participate in ways appropriate to their age, communication style, and developmental stage.
• Assent means children agree to therapy activities in the moment, even if formal consent rests with parents/carers.
• Children’s refusal, hesitation, or discomfort must be respected, and therapy adapted accordingly.

Accountability

• Each staff member is accountable for maintaining confidentiality and ensuring that consent and assent are respected.
• Staff are accountable for how AI tools are used in their role. AI use must comply with this policy, follow the practical instructions embedded in clinical templates, protect confidentiality, and always be reviewed for accuracy before being shared or recorded.
• Any concerns about confidentiality, consent, or AI use must be reviewed in supervision, with a focus on reflection, learning, and strengthening practice to safeguard families and uphold professional standards.
• If a staff member becomes aware of a potential confidentiality issue, they must raise it promptly with their supervising clinician or the Clinical Director so it can be reviewed and addressed appropriately.
• Accountability is shared across the team — through supervision, reflection, and constructive situational feedback we support one another to uphold confidentiality and respect the rights of children and families.

How to Raise a Concern

If staff identify an issue with confidentiality, consent, assent, or AI use, they must:

1. Raise the concern directly with the staff member involved, where appropriate.
2. If unresolved, escalate to their supervisor or the Clinical Director.
3. Document the concern in service records if relevant, using objective and minimal information.
4. Use supervision or debriefs to reflect on the issue and strengthen future practice.
5. Where concerns affect child safety, escalate immediately under the Child Safety Policy.

Related Policies and How They Connect

• Child Safety Policy – ensures consent, assent, and confidentiality processes protect children’s rights.
• Clinical Documentation Policy – clarifies how consent and confidentiality are documented across clinical notes and service records.
• Communication Standards Policy – outlines safe and secure communication practices.
• Roles & Responsibilities Policy – specifies role-specific duties in relation to confidentiality, consent, and AI use.
• Supervision & Performance Policy – provides reflective spaces to review confidentiality, consent, and AI use.
• Therapy Plan Policy – ensures family-friendly and clinical versions of therapy plans capture consent and assent.
• Governance & Quality Policy – outlines how this policy is monitored, reviewed, and continuously improved.
• Artificial Intelligence (AI) Use Policy – ensures AI is used safely and confidentially.

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Document Control: v1.1 · Created: Aug 2025 · Updated: Sep 2025 (added AI cross-reference; strengthened accountability language) · Review: Annual (Jan 2026) · Owner: △△D Pty Ltd

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