Standards for the Protection of Minors

STANDARDS FOR THE PROTECTION OF MINORS

in an individual specialized medical practice

Claudia Baluta-Górecka Individual Specialized Medical Practice - Holistica

NIP: 7251793243 REGON: 101512578

practice address: ul. Pustynna 53 lok. R, 93-479 Łódź

e-mail: kontakt@holistica.pl tel.: 730 888 010

Full version

effective from 1 May 2026.

CHAPTER I. GENERAL PROVISIONS

These Standards for the Protection of Minors, hereinafter referred to as the "Standards," set out the rules for protecting minors from harm within the activities carried out by Claudia Baluta-Górecka Individual Specialized Medical Practice - Holistica, hereinafter referred to as the "Practice."

The Standards apply to the physician operating the Practice and to any person cooperating with the Practice who, due to their duties, may have contact with a minor or with their data in connection with the provision of health services, organization of appointments or handling of inquiries.

The Standards apply to contacts taking place in person, by telephone, via video consultations, through registration and medical documentation systems and through the Practice's official communication channels.

The primary principle of all actions taken regarding a minor is acting in the minor's best interest, with respect for dignity, privacy, the right to information, the right to be heard and the right to safety.

The Standards are applied with consideration for the minor's age, level of maturity, state of health, mental condition, disability, special communication needs and family situation.

CHAPTER II. LEGAL BASIS AND PURPOSE OF THE STANDARDS

The Standards have been developed in particular on the basis of provisions concerning the protection of minors, patient rights, provision of healthcare activities, the medical profession, medical documentation, data protection and counteracting domestic violence.

The purpose of the Standards is to:

prevent harm to minors in connection with the Practice's activities,
define safe relationships between a minor and the Practice staff,
establish the manner of responding to suspected harm to a minor or to information about such harm,
ensure lawful documentation, storage and monitoring of reports and interventions,
regulate the protection of minors in telemedicine and in electronic communication.

CHAPTER III. DEFINITIONS

minor - a person who has not reached 18 years of age;

Practice - Claudia Baluta-Górecka Individual Specialized Medical Practice - Holistica;

Practice staff - the physician operating the Practice and any person cooperating with the Practice on any basis who may have contact with a minor;

guardian - a legal representative, legal guardian or other person authorized to represent the minor in accordance with the law;

harm to a minor - any act or omission that violates the welfare of a minor, in particular physical, psychological or sexual violence, neglect, exploitation, humiliation, degradation, intimidation or exposing to danger;

teleconsultation / video consultation - a health service provided using IT systems or communication systems;

event threatening the welfare of a minor - any situation that may indicate harm to a minor, a threat to their safety or a breach of the Standards.

CHAPTER IV. RESPONSIBLE PERSONS

Dr. Claudia Baluta-Górecka is responsible for the implementation, application, monitoring and periodic evaluation of the Standards.

The person responsible for preparing the staff to apply the Standards, receiving reports, maintaining the incident register and undertaking interventions is Dr. Claudia Baluta-Górecka.

The person responsible for filing notifications of suspected offenses against a minor, notifying the family court and — as a person practicing a medical profession — initiating the "Blue Card" procedure is Dr. Claudia Baluta-Górecka.

If a report concerns the physician operating the Practice or a conflict of interest prevents impartial action within the Practice, reports are made directly to the Police, the public prosecutor's office, the family court, the Patient Ombudsman or another competent authority.

CHAPTER V. RULES FOR SAFE RELATIONSHIPS BETWEEN STAFF AND A MINOR

1. General rules

staff treat the minor with respect, patience and empathy,
communication with the minor is adjusted to their age, health condition and cognitive abilities,
the minor has the right to ask questions, express concerns and receive understandable information,
after reaching the age of 16, the minor has the rights to participate in treatment decisions in accordance with applicable law,
staff take into account the presence and role of the guardian to the extent required by law, the patient's best interest and the nature of the service.

2. Prohibited behaviours

use of physical or psychological violence or any form of humiliation, ridiculing, degradation or intimidation,
establishing private, emotional or sexual relationships with a minor,
communicating with a minor outside the Practice's official channels for purposes other than directly related to providing services or organizing an appointment,
contacting a minor via private social media profiles, private messengers or a staff member's private phone number,
recording the image, voice or content of a consultation without legal basis and without observing information security rules,
leaving a minor uninformed about what is happening during a visit, if providing such information is possible and medically appropriate.

3. Rules concerning physical contact and examination

any examination or assessment of health status is preceded by an explanation of its purpose and course, appropriate to the minor's age,
physical contact may only be medically justified, professional and limited to the necessary extent,
when an examination of a minor is required, the presence of a guardian or another authorized person is sought unless the law or the patient's best interest justify a different approach,
for services provided remotely, staff do not request sharing images of the minor's body beyond what is necessary to provide the service and do not ask for actions that would violate their intimacy unless absolutely necessary and lawful and in the patient's best interest.

CHAPTER VI. RULES FOR SAFE RELATIONSHIPS BETWEEN MINORS

The Practice does not organize group activities, chats or shared online spaces for minor patients. Contacts between minors within the Practice's activities are incidental in nature.

In the event of contact between minors in connection with the Practice's activities, mutual insulting, mocking, violence, threats, recording or sharing images without consent and disclosing another patient's health data are prohibited in particular.

Staff respond to observed signs of violence, ridicule, cyberbullying or privacy violations between minors.

CHAPTER VII. SPECIAL RULES FOR THE PROTECTION OF MINORS IN TELEMEDICINE AND ELECTRONIC COMMUNICATION

Health services for minors are organized and provided using the Practice's official, secured communication channels, in particular registration and medical documentation systems, the official telephone and official e-mail.

Before starting a remote service, the physician verifies the identity of the minor and the guardian, as well as the guardian's authorization to act on behalf of the minor, in particular based on identification data, verification questions, medical records and, if necessary, by viewing an identity document during a video call.

The medical record notes the form of the service, the communication channel used and the presence of a guardian or the basis for proceeding without their presence.

The minor and the guardian are informed of the need to ensure privacy on their side, in particular by using a device in a place that allows for a free and confidential conversation.

The Practice does not conduct medical consultations through private social media profiles. The Practice's social media are for informational and promotional purposes only.

Recording consultations by staff is not permitted unless such an obligation results from law or there is another valid legal basis. The Practice does not record audio-visual materials from consultations solely for organizational purposes.

If it is not possible to reliably establish identity, confirm the guardian's role, or if conditions prevent a safe consultation, the physician refuses to provide the remote service or discontinues it and proposes a safe way to proceed.

If during a teleconsultation there is a suspicion that the minor cannot speak freely, is being controlled by a third party or is in a threatening situation, the physician adapts the communication method to the circumstances, assesses the risk and undertakes an intervention appropriate to the situation.

Rules for using electronic devices with Internet access

The Practice does not provide minors with devices or Internet access for independent use at its premises.
Links to consultations, login data and other access information must not be shared with unauthorized persons.
It is prohibited to send offensive, pornographic, violent content, content violating personal rights or disclosing another person's health data in channels run by the Practice.
If staff obtain information about harmful content or online threats concerning a minor, they document it and take actions appropriate to the nature of the threat.

CHAPTER VIII. RECRUITMENT RULES AND ADMISSION OF PERSONS TO CONTACT WITH MINORS

Before admitting a person to work or cooperate in a role involving contact with minors, the Practice conducts verifications required by law, in particular by obtaining information from the Register of Offenders of Sexual Crimes with restricted access and relevant information from the National Criminal Register or declarations provided for by law.

For persons with citizenship other than Polish or who have resided in other countries in the last 20 years, additional requirements regarding information from foreign criminal registers or substitute declarations apply.

Each person admitted to contact with minors confirms that they have read the Standards and undertakes to comply with them.

Documents related to verification and staff preparation are stored confidentially, in accordance with data protection rules.

CHAPTER IX. PREPARING STAFF TO APPLY THE STANDARDS

Before starting tasks that may involve contact with a minor, a person cooperating with the Practice is acquainted with the Standards, confidentiality rules, basic symptoms of harm to minors and the method of reporting incidents.

Staff preparation also includes discussion of the specifics of protecting minors during teleconsultations, rules for verifying identity and the guardian's role, safe electronic communication rules and the basics of the "Blue Card" procedure.

Familiarization with the Standards and training are documented by a signed declaration, a confirmation e-mail, an attendance list or another durable form of documentation.

CHAPTER X. RULES AND PROCEDURE FOR INTERVENTION IN CASE OF SUSPECTED HARM TO A MINOR

1. Sources of information about possible harm

the minor's statement,
information from a guardian, a close person, school, another medical entity or a witness,
observation of behaviour, family relationships or the minor's mental state,
visible injuries, neglect, signs of violence, symptoms of anxiety, severe stress, self-harming behaviours or sexualization inappropriate for the age,
circumstances revealed during a teleconsultation, including signals indicating that the conversation is controlled by a third party.

2. Immediate actions

The person who suspects harm to a minor documents the available information and immediately forwards it to the person responsible indicated in Chapter IV.

If there is an immediate threat to the minor's life or health, emergency assistance must be called at 112 or the minor should be referred to the appropriate emergency facility, followed by further legal steps.

The conversation with the minor should, as far as possible, take place in conditions that ensure a sense of safety, with respect for dignity, without exerting pressure and without suggesting answers.

3. Qualification of further actions

if there is suspicion of a crime against a minor - a report is filed with the Police or the public prosecutor's office,
if there is a threat to the minor's welfare that does not require immediate criminal reporting - consideration is given to notifying the family court about the need to review the minor's situation,
in cases of suspected domestic violence the physician, as a person practicing a medical profession, may initiate the "Blue Card" procedure by completing the "Blue Card - A" form,
if necessary to secure the minor's health, essential medical assistance is provided and, where appropriate, a medical certificate regarding the causes and type of bodily injuries related to the use of domestic violence is issued according to the current template specified in regulations.

4. Rules for contact with the guardian

As a rule, the guardian is informed about the incident and planned actions, unless circumstances indicate that they may be the perpetrator of violence or informing them could endanger the minor's safety.

If the suspicion concerns a person present during a remote consultation, the physician acts taking into account the realities of the situation, the minor's safety and the ability to effectively contact the appropriate services.

CHAPTER XI. SUPPORT PLAN FOR THE MINOR AFTER DISCLOSURE OF HARM

After the disclosure of harm or after obtaining credible information about harm, a support plan for the minor is established, appropriate to the scope of the Practice's activities, the minor's health needs and the protective actions undertaken.

The support plan may include, in particular: assessment of the urgency of medical and psychiatric intervention, indication of urgent crisis assistance, contact with a guardian who is not the perpetrator, provision of information about available forms of assistance, referral to the appropriate medical or psychological entity, as well as cooperation with authorities and institutions authorized to protect the minor.

The support plan is documented in the medical record or in internal incident documentation, observing the principle of data minimization and professional secrecy.

CHAPTER XII. DOCUMENTING INCIDENTS AND STORAGE RULES

Every report, suspicion of harm, breach of the Standards and any intervention taken are documented.

Internal documentation includes in particular the report card and the register of incidents related to suspected harm or harm to minors.

Documents related to reports and interventions are stored in a way that ensures confidentiality, integrity and access only to authorized persons.

If information about an incident is relevant to the diagnostic-therapeutic process, it is also recorded in the medical documentation to the extent necessary and in accordance with regulations.

CHAPTER XIII. DATA PROTECTION AND CONFIDENTIALITY

Processing of personal data in connection with applying the Standards is carried out in accordance with data protection regulations, patient rights and medical secrecy rules.

Access to information about an incident, report or intervention is granted only to persons who need to know this information in connection with performing their duties or on the basis of legal provisions.

Transfer of data to authorities and institutions takes place only within the limits of a legal basis and to the extent necessary to protect the minor or fulfill legal obligations.

CHAPTER XIV. MAKING THE STANDARDS AVAILABLE

The Standards are made available on the Practice's website and at the Practice premises in the full version and in a shortened version intended for minors.

If contact with the patient is conducted exclusively or predominantly remotely, information about the availability of the Standards is also provided during registration, in electronic communication or upon request of the patient or guardian.

The shortened version contains information relevant to minors and constitutes Appendix No. 13 to these Standards.

CHAPTER XV. MONITORING, REVIEW AND UPDATING OF THE STANDARDS

The Standards are subject to evaluation at least once every 2 years and each time in the event of changes in legal provisions, changes in the Practice's operating model or the disclosure of a need to supplement them.

Conclusions from the evaluation of the Standards are documented in writing. Surveys, analysis of reports, case reviews and staff feedback may be used for monitoring.

The register of changes introduced to the Standards constitutes Appendix No. 12.

CHAPTER XVI. FINAL PROVISIONS

These Standards come into force on the day ………………… 2026.

Appendices constitute an integral part of the Standards.

........................................................

Dr. Claudia Baluta-Górecka

ANNEX NO. 1

Declaration of no criminal record and of having read the Standards

I, the undersigned ........................................................................................................,

PESEL number ....................................................................................................................................,

declare that:

I have not been convicted of offenses against sexual freedom and morality or of offenses committed with the use of violence against a minor,
there are no criminal or disciplinary proceedings against me in the above scope,
I have read the Standards for the Protection of Minors in force at Claudia Baluta-Górecka Individual Specialized Medical Practice - Holistica and undertake to comply with them.

I am aware of the criminal liability for making a false statement.

place and date: .....................................................................

legible signature: ...........................................................................

ANNEX NO. 2

Declaration on the country or countries of residence during the last 20 years

I, the undersigned ........................................................................................................,

PESEL number ....................................................................................................................................,

declare that:

I have not resided in the last 20 years in countries other than the Republic of Poland and the country of my citizenship,
I have resided in the last 20 years in countries other than the Republic of Poland and the country of my citizenship, namely: ....................................................................................................................................................

I am aware of the criminal liability for making a false statement.

place and date: .....................................................................

legible signature: ...........................................................................

ANNEX NO. 3

Declaration in case of lack of information from the criminal record

I, the undersigned ........................................................................................................,

PESEL number ....................................................................................................................................,

declare that the law in the country of citizenship ........................................................................ and in the country where I resided ........................................................................ does not provide for the preparation of information from the criminal register or does not maintain such a register.

I further declare that I have not been finally convicted for acts corresponding to offenses specified in regulations requiring verification of a person admitted to contact with minors and that no ban has been imposed on me to perform activities related to the treatment of minors or care for them.

I am aware of the criminal liability for making a false statement.

place and date: .....................................................................

legible signature: ...........................................................................

ANNEX NO. 4

Report card for suspected harm or harm to a minor

Concerning the minor (name and surname, date of birth):

................................................................................................................................................................................

Reporting person (name and surname, role, contact details):

................................................................................................................................................................................

Source of knowledge or information about the incident:

................................................................................................................................................................................

Date and form of the report:

................................................................................................................................................................................

Description of circumstances, the minor's statements, observations or other facts:

................................................................................................................................................................................

Data concerning the potential perpetrator or person creating a threat:

................................................................................................................................................................................

Immediate actions taken:

................................................................................................................................................................................

Decision regarding further actions (Police / prosecutor's office / family court / Blue Card / other):

................................................................................................................................................................................

Person receiving the report:

................................................................................................................................................................................

ANNEX NO. 5

Register of incidents of suspected harm or harm to minors

No.

Minor's data

Date and description of the incident

Intervening person

Actions taken / notified entities

Remarks

ANNEX NO. 6

Confidentiality declaration

I, the undersigned ........................................................................................................,

declare that I have been acquainted with the rules of personal data protection, medical secrecy and the Standards for the Protection of Minors in force at Claudia Baluta-Górecka Individual Specialized Medical Practice - Holistica.

I undertake to maintain the confidentiality of information obtained in connection with reports and interventions concerning minors and to process data only to the extent necessary to perform my duties.

place and date: .....................................................................

legible signature: ...........................................................................

ANNEX NO. 7

Auxiliary template for a notification of suspected crime

Place, date ........................................

Notifier: Claudia Baluta-Górecka Individual Specialized Medical Practice - Holistica

correspondence address: ul. Pustynna 53 lok. R, 93-479 Łódź

District Prosecutor's Office / Police Station competent for the place of the incident

Notification of suspected commission of an offense to the detriment of a minor

I hereby notify you of a suspicion of the commission of an offense to the detriment of a minor:

................................................................................................................................................................................

Justification:

................................................................................................................................................................................

A person who can provide further information is:

................................................................................................................................................................................

signature of the authorized person: ...........................................................................

ANNEX NO. 8

Auxiliary template for a motion to review the minor's situation

Place, date ........................................

District Court ........................................ Family and Juvenile Division

Applicant: Claudia Baluta-Górecka Individual Specialized Medical Practice - Holistica

correspondence address: ul. Pustynna 53 lok. R, 93-479 Łódź

Participants in the proceedings: ........................................................................................................

Motion to review the minor's situation and issue appropriate care orders

I request a review of the minor's situation:

................................................................................................................................................................................

Justification:

................................................................................................................................................................................

signature of the authorized person: ...........................................................................

ANNEX NO. 9

Short procedure for action in cases of domestic violence / the "Blue Card"

If there is a justified suspicion of domestic violence against a minor, the physician — as a person practicing a medical profession — may initiate the "Blue Card" procedure by completing the "Blue Card - A" form.
The conversation is conducted with respect for the dignity and safety of the person experiencing violence. In the case of a minor, the presence of a guardian is taken into account, unless they may be the perpetrator of the violence or their presence endangers the minor's welfare.
After initiating the procedure, the form is forwarded to the locally competent interdisciplinary team.
If necessary, the physician provides essential medical assistance and — when grounds exist — issues a medical certificate regarding the causes and type of bodily injuries related to the use of domestic violence according to the current template specified by the Minister of Health.
The "Blue Card" procedure is independent of notifying about a suspected crime and does not exclude the obligation to inform the Police or the public prosecutor's office when grounds exist.
The Practice stores current templates of the "Blue Card" forms resulting from generally applicable regulations.

ANNEX NO. 10

List of phone numbers and assistance locations

Name / type of assistance

Contact details

Emergency number

112

Helpline for children and adolescents

116 111

Children's Helpline of the Commissioner for Children's Rights

800 12 12 12

Helpline for parents and teachers regarding child safety

800 100 100

Blue Line

800 120 002

Victim Assistance Line

+48 222 309 900

ANNEX NO. 11

Survey monitoring the application of the Standards

Question

Yes

Do you know the Standards for the Protection of Minors in force at the Practice?

Do you know the procedure for reporting events that threaten minors?

Can you recognize the basic symptoms of harm to minors?

Do you know how to react in case of suspected harm to a minor?

Do you know the rules for protecting minors during teleconsultations and electronic communication?

Do you have comments or suggestions for changes to the Standards?

Space for additional comments:

..............................................................................................................................................................................

ANNEX NO. 12

Register of changes introduced to the Standards

Date

Scope of change

Remarks

Signature

ANNEX NO. 13

Short version for minors

Hi! You are receiving medical help at Holistica. We want you to feel safe — also during an online visit or a phone call.

You have the right to know what is happening during the visit and why the doctor asks questions.
You have the right to say how you feel, what you are afraid of and what you don't understand.
If you are 16 or older, you have the right to participate in decisions about treatment in accordance with the law.
You can ask for simpler explanations or for information to be repeated.
The doctor and people cooperating with the Practice must treat you with respect and must not mock you, shame you, frighten you or insult you.
No one from the Practice should message you privately on social media or propose private contact outside medical matters.
An online visit should take place in as calm and private a place as possible. If you cannot speak freely, try to signal this to the doctor.
If someone harms you, threatens you, hits you, exploits you, yells at you or you are afraid to go home — tell the doctor. You can also call 116 111 or 800 12 12 12. In an emergency, call 112.
If something about a doctor's or another Practice person's behaviour seems wrong to you, you or your guardian can report it.

Practice contact: kontakt@holistica.pl, tel. 730 888 010