JWFC COURT ORDERED TREATMENT CONTRACT

JORDAN WEST FAMILY COUNSELING
COURT ORDERED TREATMENT CONTRACT
If you need documentation sent to the court you must: 1) Sign a release 2) provide contact information3) provide days' notice. Payment is required at the time of service. If your payment is not paid at the time of service you will not be allowed to attend the session. A letter will be sent to the court that you are out of compliance. At the conclusion of treatment a report and certificate will be issued basedon successful completion of treatment. Certificate will not be issued to individual who have an outstanding balance or have not attended all the required treatment.

ASSESSMENTS
ASSESSMENTS (Check all that apply)

Anger Assessment (fee per hr.)Drug & Alcohol Assessment (fee Per hr.)D. V. Offender Assessment (fee per hr.)D. V. Survivor Assessment (fee Per hr.)Dual Assessment (D&A/ D V) (fee per hr.)Mental Health Assessment (fee per hr.)MH Assessment/parenting (fee per hr.)Psychological Evaluation (fee per hr.)

	Drug & Alcohol Assessment (fee Per hr.)
Clinician
Date
Time
Cost
Payment
Balance

	D. V. Offender Assessment (fee per hr.)
Clinician
Date
Time
Cost
Payment
Balance

	D. V. Survivor Assessment (fee Per hr.)
Clinician
Date
Time
Cost
Payment
Balance

	Dual Assessment (D&A/ D V) (fee per hr.)
Clinician
Date
Time
Cost
Payment
Balance

	Mental Health Assessment (fee per hr.)
Clinician
Date
Time
Cost
Payment
Balance

	MH Assessment/parenting (fee per hr.)
Clinician
Date
Time
Cost
Payment
Balance

	Psychological Evaluation (fee per hr.)
Clinician
Date
Time
Cost
Payment
Balance

Level 1 -Education
Level 1 Treatment Check all that apply

Prime for Life (16 hr. 4-4 hr. sessions)Prime for Life/Misdemeanor workbookAnger Management (8) 1 hr. weeklyMisdemeanor Theft (5) hrs. 1 dayParenting Groups (fee per group)Cognitive Restructuring: (Thinking errors; conflict Resolution; Anger; Communication; interpersonal skills)Community Services Hour tracking

	Prime for Life/Misdemeanor workbook
Clinician
Date
Time
Cost
Payment
Balance

	Parenting Groups (fee per group)
Clinician
Date
Time
Cost
Payment
Balance

	Cognitive Restructuring: (Thinking errors; conflict Resolution; Anger; Communication; interpersonal skills)
Clinician
Date
Time
Cost
Payment
Balance

	Community Services Hour tracking
Clinician
Date
Time
Cost
Payment
Balance

Level 2 –Clinical Treatment
Level 2 Treatment (Check all that apply)

Substance Group (non- driving) 4 individual 16 groupsPrime Solutions After PFL 4 8 12 16 individual 16 24 32 groups (Lucinda Only)D&A Substance Use treatment groups ( 12 16 24 32 )Domestic Violence Survivors Individual 5 8 12 16 20Domestic Violence Level A 4 Individual 16 groupsDomestic Violence Level B 6 individual 24 groups OffenderDomestic Violence Level C 8 individual 32 groups Offender

	Substance Group (non- driving) 4 individual 16 groups
Clinician
Date
Time
Cost
Payment
Balance

	Prime Solutions After PFL 4 8 12 16 individual 16 24 32 groups (Lucinda Only)
Clinician
Date
Time
Cost
Payment
Balance

	D&A Substance Use treatment groups ( 12 16 24 32 )
Clinician
Date
Time
Cost
Payment
Balance

	Domestic Violence Survivors Individual 5 8 12 16 20
Clinician
Date
Time
Cost
Payment
Balance

	Domestic Violence Level A 4 Individual 16 groups
Clinician
Date
Time
Cost
Payment
Balance

	Domestic Violence Level B 6 individual 24 groups Offender
Clinician
Date
Time
Cost
Payment
Balance

	Domestic Violence Level C 8 individual 32 groups Offender
Clinician
Date
Time
Cost
Payment
Balance

JORDAN WEST FAMILY COUNSELING