Agreements and Disclosures (4 Week Preventative Contract)

Agreements*

Select All
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. Please check the boxes to acknowledge the following terms:

$800.00 prepaid for a four week commitment to parent coaching focused on preventative measures in order to keep the family intact in the home OR
$900.00 paid in weekly payments over the course of four weeks, for a four week commitment to parent coaching focused on preventative measures in order to keep the family intact in the home
Contract includes preventative support which includes: 1 scheduled weekly session, weekly collaboration with the child's outpatient therapist to increase transparency and collaboration between therapist and parents, crisis support that allows a response from parent coaches within 24 hours for support to navigate a parent in crisis, weekly emails and text exchanges focused on brief solution-focused guidance and that encourage continued progression for parents in between scheduled parent sessions.

Additional Comments and Special Arrangements*

Please check the boxes to acknowledge the following terms:

Select All
If weekly billing is needed AND agreed upon, the agreed upon payments will be due at the beginning of each week. Unpaid invoices will result in the suspension of future sessions.
For clients who wish to continue with services AFTER the 4 week 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.

I will pay by credit card
I will pay by direct deposit

Your Name*

First Last

Email*

Today's Date*

Signature*

Comments

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