Agreements and Disclosures (Special 3 Month Contract)

Agreements*

I authorize Solutions Parenting Support, its employees and Independent Contractors to email any correspondence regarding parent coaching I receive or related topics to my provided email address.
I authorize Solutions Parenting Support, its employees and Independent Contractors to collaborate with outside referral sources and outpatient therapists as documented only on the release of information form that I provide.

Disclosures*

I understand Solutions Parenting Support, its employees and Independent Contractors cannot be held responsible for being unable to access me due to telephone devices that may block their calls, my use of a pager system in which I cannot be directly reached, any form of caller identification, or any type of device that does not allow my parent coach to make direct telephone contact with me.

Financials*

The usual and customary rate for providing parent coaching services through Solutions Parenting Support:

$2500.00 for a three month commitment, which includes 1.5 hours of weekly individual coaching, 1 weekly treatment team call and 30 minutes weekly of contact via email throughout the three month contract. For additional time in the week, the parent agrees to pay and additional $90 per hour.

Additional Comments and Special Arrangements*

I acknowledge that if monthly billing is needed AND agreed upon, the agreed upon payments will be due at the beginning of each month. Unpaid invoices will result in the suspension of future sessions. For clients who wish to continue with services AFTER the three month commitment, we have available 3 month, 1 month, as well as 3 or 5 prepaid session contracts, all at a discounted rate, for ongoing coaching services. These payments must be prepaid in advance to continue with scheduled sessions and services. Unpaid invoices will result in suspension of future sessions.

Payment Types

An invoice with be sent via Square, where all credit cards are accepted. Information will be provided for those desiring to do direct deposits.

Your Name*

First Last

Email*

Today's Date*

Signature*

Phone

This field is for validation purposes and should be left unchanged.