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NAME AND AGES OF CHILDREN (With other
parent ONLY)
Child 1, first and last name:
age:
Child 2, first and last
name: age:
Child 3, first and last name:
age:
Child 4, first and last
name: age:
Were you asked (or ordered) by a court to contact us?
Yes
No If so, which
court? (city and county) Case
number, if known: Next
court date: YOUR ATTORNEY:
Your attorney's phone:
OTHER PARENT'S ATTORNEY:
Their attorney's phone:
Do you and/or your co-parent have current restraining orders?
Yes
No Please
read the following carefully. When you are done, please click the submit button.
You will need to sign your name and indicate the date on an actual form prior
to class.
I
understand that I will be enrolled in one or more divorce education classes. I
understand that divorce education is not counseling or psychotherapy. I will pay
for my enrollment in divorce education either in advance, or at the time I arrive
to attend a class for which I have a confirmed appointment. I will pay for my
enrollment with cash, a valid credit card, or a money order. No checks are accepted
for payment. If I am scheduled to attend a class and do call within 24 hours of
my appointment to cancel or reschedule, I will pay an additional 'no show' fee
of $30 as a condition of attending divorce education. I
understand that the instructor in my class may be a licensed mental health professional.
If so, I understand that, as required by California law, a licensed mental health
professional must make an official report to appropriate law enforcement agencies
if he or she suspects anyone poses a a threat to harm oneself or others, has abused
a child, or poses a risk to do so. Except for reasons such as this, I am entitled
to confidentiality. If, however, the court has ordered the staff of Solutions
For Families to communicate to it (the court) about my participation in any phase
of divorce education and/or mediation, I understand that the court order overrides
my right to confidentiality. Further, I understand that any fees I pay for any
divorce education and/or mediation service offered by Solutions for Families does
not obligate the staff of Solutions for Families without compensation to write
a report, testify in court, or participate in settlement proceedings. If
I have been ordered by the court to attend Solutions for Families Part B (Co-parenting),
or consent on my own to do so, I understand that the staff of Solutions for Families
may need to share very limited information with others (such as my co-parent,
my child's attorney). Such information would be limited, unless I agree otherwise,
to the following: (a) whether I have attended Part A, (b) whether I have expressed
a willingness to take Part B (Coparenting), (c) whether I am scheduled to take
Part B, or (d) whether, after taking Part A, I decline to take Part B. Any such
information will be shared with others only if doing so is necessary on the part
of the staff of Solutions for Families to schedule Part B (Co-parenting).
Click box to indicate that you have read and agreee to the above terms and conditions.
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