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Informed Consent / Financial Responsibility Form

I, , voluntarily consent to the following court- related service(s) with Jordana Wolfson, LMSW, Ed. Specialist, MA.:

Parenting Time Coordination - Court-Ordered intervention in decision-making for children where specific stipulations are set forth by the Court for Co-Parenting Solutions, LLC to resolve disputes of the family. The scope of this work is determined through a specific Court Order naming Co-Parenting Solutions, LLC/Jordana Wolfson as the Parent Coordinator that must be signed by both parties.

Co-Parenting Counseling – Court-Ordered educational and therapeutic intervention to improve the Co-Parenting relationship through learning about the positive impact of cooperative Co- Parenting on children and striving toward effective communication to improve Co-Parenting in two homes.

Reunification Therapy – Court-Ordered therapeutic intervention for families in two homes when the child(ren) find difficulty visiting with and/or having a positive relationship with one parent.

Supervised Therapeutic Parenting Time - Court-Ordered therapeutic intervention and visitation for families in two homes when the child(ren) find difficulty visiting with and/or having a relationship with one parent and the parent is ordered by the Court to only visit with their child in the supervised therapeutic setting that Co-Parenting Solutions, LLC can provide.

I am aware of the reasons for these services. I also understand that these services differ from traditional mental health services in the following ways:

Limits to Confidentiality
I am aware that these services are not confidential. Anything I say might be quoted in a written report. If these serves are court-ordered, reports or treatment updates will be released to the agency requesting these services. I am also aware that the clinician may discuss my case with other professionals clearly involved with these services or while participating in quality improvement activities. I understand that there are specific situations when the clinician will be required to report to appropriate authorities any information I reveal that clearly indicates a danger to myself or others (e.g. potential suicide or homicide). My clinician is also required by law to report any knowledge of abuse or neglect of a child, or of an incompetent, disabled, or otherwise restricted person.

Impartiality
I understand that the clinician will describe the results of services in an impartial and professional manner. I am aware that payment for these services in no way guarantees a favorable outcome for the payer.

Dual Relationship Statement
I understand that other forms of psychological services beside those endorsed above may not be provided by the same clinician. This is to prevent a potential conflict of interest that could result in my not getting full benefit of the above indicated services.

Access to Records
I am aware that while I have the right to information regarding any records of shared appointments with other adults I am participating in this service with, I will not have access to information gathered during individual appointments with that adult or a record of their billing and appointment attendance. I understand that biological parents/legal guardians of any minor children participating in counseling may have a right to access their medical record, unless limited by court order or as permitted or required by law, and in some circumstances not disclosed as determined in the professional judgment of the therapist.

Payment
I understand that I am responsible for payment of all charges due for services rendered. I understand that a copy of reports may not be sent until services are paid in full, and that additional reports may be subject to charge. I understand that I will be billed at a rate of $180/hour in 15-minute increments for all non-session professional activities such as review of collateral information, review of ongoing correspondence or communication with health or legal providers related to the case. The cost for services for any written letters requested from the Co-Parenting Counselor will start with a $250 fee PLUS the hourly rate of $180/hour for the time taken to research, prepare and write the letter.

Retainer
For intervention services (e.g. Parenting Time Coordination, Reunification Therapy) a retainer of $1,000 shall be provided by the client at the outset of services. If more than one client is participating in services, the expense of the retainer shall be split according to the order for said services or the Judgment of Divorce if no specific service order exists. The retainer will be charged for non- session professional activities such as review of collateral information, review of ongoing correspondence or communication with health or legal providers related to the case. The retainer will be charged episodically, typically on a monthly basis. A full report of professional activities can be requested at any time. When the retainer account falls below $180, a replenishment will be required. If the balance falls to zero the services may be suspended. At the end of the service provision any unused amounts shall be returned according to the portion paid.

Court Testimony
The purpose of Co-Parenting Counseling is to empower both parties to communicate and problem-solve more effectively with one another and not to utilize the Co-Parenting Counselor for ongoing litigation between parties. If being subpoenaed to testify in court, please remember that all testimony will be from a place of neutrality and not to bolster either party’s stance in litigation circumstances. Court testimony requires a $1,000 retainer (non-refundable if the case settles and/or court is cancelled for any reason). The cost of services for court testimony is $2,000 for half a day (1-3 Hours) and $4,000 for a full day (3.5-7 Hours).

Cancellation Policy
I am aware that if I cannot attend a set appointment, I need to give notification at least 24 hours in advance. If I do not give 24-hour notification, I am aware that I will be responsible to pay a fee of $180. If participating in Co-Parenting Counseling, the parent who cancels the appointment without 24-hour notification will be charged the $180 fee.

Duration of Consent
I am aware that I may withdraw my consent at any time with appropriate written notice. However, I agree that this authorization will remain in effect for the duration of all professional services rendered, or until such authorization is revoked in writing. I understand that any written or verbal disclosures made prior to revocation of consent are not subjected to confidentiality, since such information has already been released.

Practical Issues
I have been made aware of reasons I might be discharged from services, including missing two or more consecutive appointments without 24-hour notification, inappropriate or threatening behavior toward the clinician or other participants in sessions, inappropriate or threatening emails or phone calls to the clinician, lack of sincere effort and cooperation toward scheduling appointments or working toward the goals determined by the court and/or clinician and any other behavior that the clinician deems is counter-productive to the process. I understand that there is no guarantee the services I receive will bring the desired result.

I, the undersigned do hereby understand and voluntarily consent to the terms and conditions described above. I have had the opportunity to have my questions answered prior to signing this form.

Please ensure you have selected and initialed the appropriate service listed near the top. Thank you.

Date Signed:

Revised 2/2022

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July 24, 2020 3:03 pm EDT

8. Contract for Court-Related Services Uploaded by Jordana Wolfson - jordana@coparentingsolutionsllc.com IP 68.60.107.55

August 18, 2020 10:07 am EDT

Document owner michael@yourppl.com has handed over this document to jordana@coparentingsolutionsllc.com 2020-08-18 10:07:31 - 75.128.132.184