This intervention agreement is an addition to the court order as well as Dr. Bennett’s Office Policies & Consent for Treatment and any relevant informed consents or Authorization for Release of Information forms.
1. Both parents have agreed that it is in the children’s best interests to have meaningful relationships with both parents. To meet this goal, they have agreed to engage the services of Dr. Tracy Bennett to restore and/or facilitate contact between _________________ and the child, ___________.
2. While the parents may have different views about the cause and reason for the children’s refusal and or reluctance to see a parent, they agree to be a part of the solution. The parents agree the objective of the family therapy intervention is not to determine IF it is in the child(ren)’s best interests to have contact with one of the parents. Rather, the parents agree it is in the child(ren)’s best interests to have meaningful relationships with both parents. The family therapy intervention is intended to help the child(ren) have healthy and meaningful relationships with both parents.
ROLE AND AUTHORITY OF DR. TRACY BENNETT
3. Dr. Bennett will not be making recommendations regarding the children’s time with each parent, parental fitness, and/or legal decision-making. Rather, she will be assisting to implement the previously agreed to and/or court-ordered parenting plan. Her role is to assist with the family therapy intervention and not as a custody assessor, arbitrator, parenting coordinator, or consultant for litigation. Dr. Bennett may make recommendations to the parents, lawyers, and the court to the extent that she has obtained sufficient information.
4. The goals of the therapy may include to:
- foster overall healthy child adjustment;
- facilitate the implementation of the previously agreed-to or court-ordered parenting time schedule;
- restore, develop, or facilitate adequate parenting and coparenting functioning and skills;
- assist the parents to resolve relevant parent-child conflicts;
- develop family communication skills and effective approaches to problem-solving;
- assist the parents to fully understand the child(ren)’s needs for healthy relationships with both parents and the negative repercussions for the child(ren) of a severed or compromised relationship with a parent in their young lives and as adults;
- restore or facilitate contact between parent and child(ren);
- assist the parents and their child(ren) to identify and separate each child’s needs and views from each parent’s needs and views;
- work with each family member to establish more appropriate parent–parent and parent-child roles and boundaries;
- correct the child(ren)’s distortions and replace these with more realistic perceptions reflecting the child’s actual experience with both parents;
- assist the child(ren) to differentiate self from others and exercise age-appropriate autonomy;
- assist each parent to distinguish valid concerns from overly negative, critical, and generalized views relating to the other parent;
- other (specify)_________________________________________.
5. The parents agree to the involvement of the entire family, in various combinations, as directed by Dr. Bennett. The process will include meetings with each parent and the child(ren) individually and jointly. The process may include meetings with other family members as deemed necessary.
6. Dr. Bennett will not be making decisions regarding the child(ren)’s parenting time with each parent (access) or legal decision-making (custody) as this is outside her role. Rather, Dr. Bennett will be assisting to implement the previously agreed-to or court-ordered Parenting Plan. Notwithstanding, the parents agree Dr. Bennett may determine the parenting time for the purposes of the therapy, the nature of transitions between the parents, rules of parental communication or engagement, location and pacing of the parent–child contact consistent with the court-ordered Parenting Plan, etc. Dr. Bennett may make recommendations deemed helpful to the child(ren) in implementing the court orders or the current agreed-to Parenting Plan.
7. Dr. Bennett may provide a report to the parents, lawyers, or the court describing the parents’ and child(ren)’s progress and cooperation, including any obstacles preventing the therapy from beginning or continuing. This may include specific statements and behaviors, which she deems necessary to adequately support other content or statements in the report. Recommendations may be provided regarding additional services or counselling where deemed appropriate. Any opinions or recommendations reported will be limited in scope to matters for which Dr. Bennett has obtained sufficient information.
8. The parents will provide all records, documentation, and information requested by Dr. Bennett as soon as possible upon request.
9. Dr. Bennett may choose to contact other previous or current professionals involved with the family members to receive and obtain information to better meet the aforementioned treatment goals. Toward this end, the parents will sign all consent forms requested by Dr. Bennett permitting the exchange of information between the relevant professionals.
10. Dr. Bennett may make recommendations for the involvement of additional professionals (e.g., individual therapist for parent or child, educational specialist, coach for parent education).
11. Dr. Bennett may make recommendations for the termination of other therapist(s) who may be currently involved with the family members.
RESPONSIBILITY OF THE PARENTS
12. The parents agree to fully cooperate, support, and wholeheartedly participate in the family therapy intervention. This includes, but is not limited to: (1) responding to Dr. Bennett within 24 hours unless determined otherwise by Dr. Bennett once the parent requests a temporary change (applicable when situations arise that would make this impossible or unreasonable, such as vacation, illness, work travel, etc.); (2) paying for services in a timely manner in accordance with the fee agreement executed by the parents; (3) ensuring the child(ren) is transported to and from scheduled therapy appointments in a timely manner, and even if the appointment does not involve that parent or if it involves the other parent; and (4) exercising parental authority to require the child(ren) to attend and cooperate with the therapy. If requested by Dr. Bennett, a parent shall bring the child when it is not that parent’s parenting time, picking up and returning the child to their school, daycare or other location as per Dr. Bennett’s instructions.
13. The parents are advised the court may consider the good-faith efforts and the parents’ demonstrated behavior during the therapy as a factor in determining any decisions about the child(ren)’s best interests, including legal custody (decision-making) or access (parenting time).
14. The parents have been advised the therapy requires each parent to make changes in their own behavior and parenting to support their child(ren)’s needs. Dr. Bennett may request specific changes in such areas as setting appropriate limits for the child(ren), encouraging the child(ren) to express feelings and solve problems appropriately, listening to the child(ren)’s concerns and actively supporting the child(ren)’s independent relationships, and shielding the child(ren) from parental conflict. The parents agree to make reasonable efforts to cooperate with the requests made by Dr. Bennett in these and any other relevant areas. If either parent disagrees with requests or recommendations made by Dr. Bennett, the parent will discuss those concerns privately with her and will not allow the child(ren) to witness or overhear the concerns.
15. Both parents will overtly support the therapy and Dr. Bennett to the child(ren). This includes respecting the child(ren)’s right not to discuss the therapy with their parents and not asking the child(ren) for information about the sessions.
16. The parents will refrain from scheduling new after-school activities, lessons, or events during the scheduled therapy appointments. Reasonable efforts will be made to schedule appointments so the child(ren) does not miss school or their currently scheduled extracurricular activities. However, this may not always be possible.
17. Given the risks of information being taken out of context or being incomplete, the parents agree they and their lawyers will not restate, summarize, or paraphrase in court documents any feedback or statements provided by Dr. Bennett during the therapy. If necessary, a report may be requested, permitting Dr. Bennett to communicate about the therapy to the court as per this Agreement and the court order.
18. There shall be no audio or visual recording of the therapy unless agreed to in writing by Dr. Bennett. Unauthorized recording of any kind may be sufficient basis for Dr. Bennett to terminate the treatment and provide a report explaining the reasons.
19. Both parents acknowledge they have had an opportunity to review this Agreement and to ask any questions they may have concerning Dr. Bennett’s approach to the therapy and other available alternatives.
DURATION OF SERVICES
20. The therapy shall continue for a minimum of 6 months, with reevaluation of the need for continued services based on the progress in meeting the goals listed above (#4). Neither parent may unilaterally withdraw from this Agreement prior to the completion of the term identified. However, with their joint consent in writing, both parents may terminate this Agreement.
The therapy shall continue until Dr. Bennett indicates the goals listed in #4 have been met, that no further progress is possible at this time, or that appointment of a different therapist is necessary.
In the event either parent wishes to terminate the therapy, they will provide 15 days’ written notice to Dr. Bennett and the other parent. The parents will attempt, with the assistance of their lawyers, to agree on an alternate to replace Dr. Bennett. If the parents are unable to agree within 30 days, an alternate will be appointed by Dr. Bennett.
21. With four (4) weeks’ notice in writing, Dr. Tracy Bennett may resign if she determines this to be in the best interests of the child(ren), in which case a referral may be made to another therapist if the therapist(s) deems this to be appropriate.
22. While Dr. Bennett is bound to maintain confidentiality and not permitted to disclose information to anyone who is not involved in the process, the parents understand the process may involve Dr. Bennett and the other relevant professionals (previous or current) sharing information (e.g., custody assessor, parent’s or child’s therapist, teacher, parenting coordinator, etc.).
23. Dr. Bennett may use discretion to disclose information obtained from the participants in the therapy to the other participants in the therapy.
24. Dr. Bennett shall be free to disclose all information, documentation, and correspondence generated by the process with the lawyer for each parent (and child’s lawyer and CAS lawyer, where present) and with the court and may speak with the lawyers ex parte. This signed Agreement serves as the parents’ informed consent for Dr. Bennett to obtain information from the court, counsel, and both parents AND for them to provide information received from all sources verbally or in a report to the court, counsel, and the other parent.
25. The parents understand Dr. Bennett is required to report to the appropriate child protection service or agency if the therapist has a reasonable suspicion a child is being physically, sexually, or emotionally abused or neglected. In addition, Dr. Bennett is obliged to notify the proper authorities if the therapist has a “reasonable suspicion” a client may harm himself or herself or the other parent.
ELECTRONIC PROVISION OF SERVICES
26. Electronic provision of services including use of email, telephone, video contacts (e.g., Zoom), and text messaging (rarely) may be provided by Dr. Bennett and requires your consent. Scheduling is usually done by email and may also be done by telephone.
27. Email may be used in the delivery of some services to augment or follow up on face-to-face or telephone sessions. In these cases, we may provide updates, invoices, account statements, summaries, draft parenting plans or memoranda, educational resources, or exchange information. Based on the nature of the service provided, these email communications may include information not only about others including your child(ren) or the other parent.
28. When consenting to the provision of services by telephone or electronically, it is important to appreciate both the risks and benefits, including insufficiency, misunderstandings due to lack of visual clues and context, and failures in technology. In the event of a technology failure when using Zoom (audio or visual), Dr. Bennett will call you by telephone at the number you provide for backup at the time of scheduling.
29. While efforts are made to protect privacy when providing services by telephone or electronically, the same degree of confidentiality provided during in-person office sessions is not possible. The limitations include the possibility of interceptions of communications while these are occurring. Every effort needs to be made from both Dr. Bennett’s and your end to minimize any interruptions during video or telephone contacts (e.g., turning off cell phones, locking the door, etc.). Towards this end, you agree to make these efforts and to advise Dr. Bennett if someone comes into the room you are in or is within earshot.
30. The benefits of using electronic communications and telephone may include appropriateness, avoiding the need to travel a distance, taking less time off work, having possible access to services continuing while the therapist is away, having the option to receive services when you are away, or for convenience or comfort. Alternatives to the provision of electronic or telephone services include in-person services only or local services from an appropriately trained and available health service provider of the same or different discipline.
31. Please keep in mind that other individuals (your spouse, new partner, child, adolescent, others living in your home) may be able to access information, sensitive or otherwise, communicated electronically or by telephone between you and Dr. Bennett. As noted, the information shared may be about others, not only you. Any communications provided by Dr. Bennett are intended for you and not for others unless agreed to otherwise. By signing this informed consent form, you are confirming that you have taken reasonable steps to secure your own electronic devices you choose to use to communicate with her (mobile phones, iPads, computers, etc.). This would include having a confidential password and adequate firewalls. You further agree not to allow others (e.g., your children of any age, new partner or spouse, parent, friend, relative, etc.) access to any communications sent to you from Dr. Bennett, unless an agreement is reached in advance that the particular communication is appropriate to share with others. (Please see separate Office Policies & Consent for Treatment for more information on privacy.)
32. Emergencies. We ask for you to identify a contact we can reach by telephone and email for use in an emergency that may arise during an office or telephone contact or during any electronically facilitated contact. If you do not attend for a scheduled meeting of any kind, we will attempt to call you twice. If we do not hear back in what is deemed to be a reasonable period of time, Dr. Bennett may choose to contact the person you have identified as your emergency contact.
33. Licensure. Dr. Tracy Bennett is licensed to practice in the state of California. Unless they are licensed in that jurisdiction, it is illegal for a psychologist to practice in a location you may be in at the time the service is delivered, even if you are a resident of California unless Dr. Bennett obtains permission from that state or province or the required form of licensure in advance of the delivery of service. In many cases, it is possible for permission or a temporary license to be obtained. By signing this agreement, you agree to advise Dr. Bennett for each telephone or video contact if you are no longer in California.
INDEPENDENT LEGAL ADVICE
34. Each of the parents confirms they have received independent legal advice prior to executing this Agreement or is aware they have a right to do so.
35. Both parents:
- understand their rights and obligations under this Agreement and the nature and consequences of the Agreement;
- acknowledge they have received and reviewed Dr. Bennett’s Office Policies & Consent for Treatment;
- acknowledge they are not under any undue influence or duress; and
- acknowledge they are signing this Agreement voluntarily.
RISKS & LIMITATIONS
36. Informed consent requires disclosure of potential risks and limitations. By signing the Agreement, the parents acknowledge Dr. Bennett cannot guarantee physical safety during the family therapy intervention. The parents further acknowledge Dr. Bennett cannot guarantee against bad faith or abuse of process by any participant. The parents understand there is no guarantee the family and coparenting functioning and the parent-child contact problem will be resolved during family therapy. The parents acknowledge they may not be fully satisfied with the outcome of the services provided.
37. Having read the above, I hereby consent to:
- willingly continuing with this family therapy intervention process;
- informing my legal counsel, or if representing myself, advising the court and the other parent in writing to let them know I choose to withdraw from the therapy;
- advising Dr. Bennett in writing if I choose to withdraw consent for this therapy;
- all information and communication provided by me being done so on a ‘with prejudice’ (not confidential) basis and for this information to be used in court if required;
- Dr. Bennett seeking full and active participation from me and other family members as she deems necessary.
38. I understand:
- what is expected of me and the relative risks of the information being used in court or this legal matter;
- the nature of this therapy, fees associated, cancellation policy (24 hours), mutual responsibilities, confidentiality issues and limitations, benefits, and risks, the consequences of non-action, the option to refuse or withdraw, and the elements of the “with prejudice” nature of this therapy;
- the signing of this Agreement/Informed Consent by me is a further acknowledgment of informed consent as it dictates the professional activities Dr. Bennett will be conducting.