Parent Coordination Registration

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This agreement for parenting coordination services shall serve as a binding contract between the Parenting Coordinator (PC) at Pattison Professional Counseling Center (PPCC, Inc.) and the undersigned individual. Both parties must sign Parent Coordination Agreements to engage in parent coordination for the specified children.

Susan Page, MA, LMHC, NCC agrees to serve as a Parenting Coordinator for the undersigned parties and their minor child(ren) in an effort to assist the parties and the child(ren); to champion the child(ren)’s rights to access to the parents; and to protect the best interests of the child(ren) in general.

1. Parent coordination is not considered therapy. Your intake and joint sessions are not eligible for third-party (insurance) reimbursement.
2. A retainer may be required to address email communications or other services. Fees will be drawn against this retainer. If the retainer becomes depleted, additional funds will be required before services continue. This will be discussed in advance at the Parent Coordination meeting.
3. The fee schedule for parenting coordination at PPCC is $130.00 per hour (2-hour minimum for the first session).
4. Reviewing documents and correspondences, emailing, communicating with parents, their attorneys, or others via telephone are billed in 15-minute increments.
5. Court appearances (including testifying and travel) and depositions are billed at $150.00 per hour. Fees for depositions and testimony must be received two weeks prior to the scheduled date. The minimum charge is four hours ($600), including travel time. Deposition and court testimony fees are non-refundable.
6. If one parent insists that the Parenting Coordinator read extensive reports, other documents, or listens to extensive audio tapes, this parent is solely responsible to pay for the time involved.
7. In the case of court testimony, the party who requests the Parenting Coordinator’s participation shall pay for the entire cost of the PC’s time.
8. The cost of joint parenting coordination services will be equally divided between the parties. The only exception is if the Parenting Coordinator is presented with a certified copy of a court order designating the responsible party for payment. Individual sessions are the sole responsibility of each parent to pay.
9. You must provide 48-hour notice if you need to cancel either an individual or a joint session. If you cancel a joint session, you must cancel with both the Parenting Coordinator and the co-parent. If you do not provide 48-hour notice or notify the co-parent, you will be responsible for the full charge of the session. Even if the other party is responsible for the full fee of each session, you will be 100% responsible for any late cancellation fees, failure to show fees, and sanctions for inappropriate behavior at the PC’s discretion.
10. If either party challenges a decision of the Parenting Coordinator in court, and the court finds that the challenge is without substantial basis or not made in good faith, the party challenging the decision will be responsible for all costs, including reasonable attorney’s fees incurred by the other party and/or by the Parenting Coordinator.
11. Invoices will be provided monthly for any remaining balance and for additional services provided. Payment is due at the time services are rendered. If your account is left unpaid after termination and is submitted to a collection agency, you will be responsible for any legal fees to obtain the unpaid balance. Non-payment of fees is grounds for the resignation of the Parenting Coordinator.

The term of the Parenting Coordinator’s service is a period of 24 months from the date of execution of this agreement or as stated by court order and may be terminated prior to the end of the term. Both parties and their attorneys will be given two weeks’ notice if the PC requests to withdraw.

This agreement cannot cover all the circumstances that may arise in every situation. The parties agree that the Parenting Coordinator may establish new rules and guidelines to fit their unique situation. The fundamental principles governing all rules and guidelines are 1) minimization of conflict between the parties and 2) decisions will be made in the best interests of the child(ren).

Where conditions of this agreement differ from the provisions of a court order regarding the service of the Parenting Coordinator, the provisions of the Court will prevail and be followed. If a court appointment is in effect and the PC or the parties wish to terminate the services of the PC, it is the responsibility of the parties to have the court vacate the appointment.

I have read and understood the above Parenting Coordination Agreement and agree to abide by its terms:

(To sign, please use your mouse, trackpad, or finger to provide your signature. You cannot continue with the form until your signature for this part of the agreement is received.)

This Consent form does not replace PPCC’s primary Informed Consent Form for “In Office” mental health services; it is in addition to.

The definition of Telehealth involves the use of electronic communications to enable PPCC, INC mental health professionals to connect with individuals using interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, treatment, referral to resources, education, and the transfer of medical and clinical data. I understand:

1. The Florida laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is confidential. I understand during my telehealth sessions my provider will ensure a private and confidential environment and I agree to do the same at my location.
2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that there are risks and consequences from telehealth, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons.
4. I understand that if my counselor believes I would be better served by another form of intervention than telehealth, I will be referred to a mental health professional that can provide “in-person” services.
5. I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.
6. I understand telehealth sessions shall not be recorded in any way by either the practitioner or client.

 

By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

I have read this document and understand the risks and benefits related to the use of telehealth services. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein.  

I hereby attest by signature that I have read, understood, and agree to the terms of this document.

(To sign, please use your mouse, trackpad, or finger to provide your signature. You cannot continue with the form until your signature for this part of the agreement is received.)

In case of an emergency, please list the emergency contact person we should call:

PPCC Inc. secures your information electronically utilizing a HIPAA HYTECH compliant service.

If you and your PC and/or our support staff communicate via email or texting through a cell phone, you agree to and understand that your information may be released via your correspondence and communications. PPCC Inc. secures your information however, once communication is released via the internet or phone devices your information is no longer secure.

(To sign, please use your mouse, trackpad, or finger to provide your signature. You cannot continue with the form until your signature for this part of the agreement is received.)

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