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Co-Parenting Solutions

Jordana Wolfson / September 28, 2022

Driving Rules & Insurance

As with everything in co-parenting, when it comes time for your children to drive, you should talk about the details far in advance, so everyone is on the same …

Jordana Wolfson / August 21, 2022

Cell Phone Safety Series, Part 2

Why give a kid a cell phone? To contact each parent independently. To have an emergency communication system at their fingertips. To be able to be tracked so …

Jordana Wolfson / July 21, 2022

Cell Phone Safety Series, Part 1

Nowadays, I write into all Parenting Agreements that if there are laptops, cell phones, tablets or other electronics that go back and forth between the homes, a …

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Co-Parenting Solutions
Jamestowne Executive Offices
31000 Telegraph Rd., Ste 280
Bingham Farms, MI 48025

248.330.5351
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Co-Parenting Solutions provides a multi-level approach to services that focuses on reducing parental conflict in order to enhance the child’s emotional functioning. Co-Parenting Solutions offers programs to address the relationship between separate households created as a result of separation or divorce.

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Collaborative Divorce with Mental Health Professional Agreement

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Please indicate who is responsible for payment or if the fees are to be split by the parties:*
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- Split
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Test Agreement

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Consent for In-Person Services During Covid-19 Public Health Crisis

Client Name*
First Last
Name of client or person acting as legal representative for the purposes of this agreement.
Client Email Address*

Email address of client or representative for purposes of this agreement.
Minor Name (if also applicable)
First Last
Client Relationship to Minor Child (if also applicable)
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Client Intake Form

Step 1 of 3

33%

Client Name (Self)*
First Last
Name of Your Co-Parent
First Last
Mobile*
Work*
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Place of Employment and Title*

How did you hear about Co-Parenting Solutions, LLC?*
Name of Therapist(s) Used for Self (if applicable)
Name(s) of Therapist(s) You Have Engaged the Services of for your Children (If Applicable)
Names of Any Legal Professionals You Have Engaged for Divorce Services
Which judge is assigned to your case?

List any professionals from Friend of the Court you are working with
Names and Ages of Shared Children
Please list shared children name(s) and age(s), one per line.
Names and Ages of Non-Shared Children
Please list non-shared children name(s) and age(s), one per line.
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Contract for Mediation Services

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Contract for Court-Related Services

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Contract for Co-Parenting Counseling and Skill Building Sessions

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Consent for Therapeutic Treatment

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Email*
Name
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Consent for Minor Therapeutic Treatment

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First Last
Client Email*
Minor Name:*
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Additional Minor Names:
Please add the first and last names, one per line, for each additional minor covered by this agreement.
Client Relationship to Minor(s):*
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Authorization to Release Confidential Information

Step 1 of 2 - Client / Signer Information

50%

Client Name*
First Last
Client Email*
Minor Name(s) and DOB (if also applicable)
One minor name and dob per line.
Maiden / Other Name
Client Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Source of Authority (if acting as legal representative of client)

This information will be released to Jordana Wolfson, LMSW, MA, ED SP, of Co-Parenting Solutions, LLC.
Person / Agency Releasing Information
List up to three entities that are authorized to release information.
Name(s) of Person/Agency*
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Person / Agency Releasing Information #2
Name(s) of Person/Agency
Phone
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Person / Agency Releasing Information #3
Name(s) of Person/Agency
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Email
Information to be Released
This authorization is in effect for up to 5 years from date of signature unless you rescind same in writing to Jordana Wolfson, 31000 Telegraph Road, Suite 280, Bingham Farms, MI 48025.
Description of Information to be Released
- Co-Parenting Counseling
- Parenting Coordination
- Parent-Child Reunification Therapy
- Collaborative Divorce
- Parenting Time Agreement
- Divorce Mediation
- Other ...
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if other, please describe
The Purpose and Need for Disclosure of Information
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Authorization for Teletherapy

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Credit Card on File Policy

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Credit Card Number*
Expiration Date*
CVC Code*
Zip Code*
Cardholder Name*
First Last
Cardholder Email*
If your credit card is declined two consecutive times, we will be requesting a retainer before proceeding with new appointments.*
- By checking this box I agree to the terms mentioned above
Phone
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Notice of Privacy

Client Name*
First Last
Name of client or person acting as legal representative for the purposes of this agreement.
Client Email Address*

Email address of client or representative for purposes of this agreement.
Client Date of Birth*
MM slash DD slash YYYY
Minor Name (if also applicable)
First Last
Client Relationship to Minor (if also applicable):
Minor Date of Birth (if also applicable):
MM slash DD slash YYYY
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Contact Us

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