Common use of Divorce and Custody Clause in Contracts

Divorce and Custody. I understand that this provider is not a custody evaluator and cannot make any recommendations on custody. She can refer me to a list of licensed psychologists who provide custody evaluation if needed. She requires a copy of the current, standing court order showing custodial rights for each parent and/or the parenting agreement that is signed by both parents and the judge at the first intake session before she is able to meet with my child. I understand that she will need to have contact with the parent who has legal custodial decision making for medical issues before she sees my child for evaluation or treatment and will need to obtain written consent for the child to participate in counseling from the legal custodian, and prefers to have contact with both parents prior to seeing my child. Legal Proceedings – I understand that I am being asked to waive the right for this provider to be summoned by subpoena to court. The policy is set in order that this provider can preserve the efficacy and integrity of my therapeutic process and my relationship with me and my child(ren). This provider’s appearance in court can damage the therapist-client relationship and it is her ethical duty to make every reasonable effort to promote the welfare, autonomy, and best interests of her clients. By signing this agreement, I am waiving my right to have this provider subpoenaed and agreeing to not to have her or her records subpoenaed. Court Testimony – I further understand that there may be other conditions (such as a court order) that may place limits on the therapist’s legal ability to maintain my confidentiality. Due to the fact that the therapeutic process often involves disclosure of many matters which are confidential in nature, it is agreed that should there be any legal proceedings neither myself, nor my attorney, nor anyone else acting on my behalf will call on this provider to testify in court or at any other proceeding, nor will a disclosure of therapy records be requested. • If this provider is required to testify for court, speak with legal counsel, prepare documentation, etc. the fee is $300.00 an hour plus mileage and expenses incurred. This provider will not testify in divorce custody or mediation. A two hour minimum will be charged.

Divorce and Custody. I understand that this provider is not a custody evaluator and cannot make any recommendations on custody. She can refer me to a list of licensed psychologists who provide custody evaluation if needed. She requires a copy of the current, standing court order showing custodial rights for each parent and/or the parenting agreement that is signed by both parents and the judge at the first intake session before she is able to meet with my child. I understand that she will need to have contact with the parent who has legal custodial decision making for medical issues before she sees my child for evaluation or treatment and will need to obtain written consent for the child to participate in counseling from the legal custodian, and prefers to have contact with both parents prior to seeing my child. Legal Proceedings – I understand that I am being asked to waive the right for this provider to be summoned by subpoena to court. The policy is set in order that this provider can preserve the efficacy and integrity of my therapeutic process and my relationship with me and my child(ren). This provider’s appearance in court can damage the therapist-client relationship and it is her ethical duty to make every reasonable effort to promote the welfare, autonomy, and best interests of her clients. By signing this agreement, I am waiving my right to have this provider subpoenaed and agreeing to not to have her or her records subpoenaed. Court Testimony – I further understand that there may be other conditions (such as a court order) that may place limits on the therapist’s legal ability to maintain my confidentiality. Due to the fact that the therapeutic process often involves disclosure of many matters which are confidential in nature, it is agreed that should there be any legal proceedings neither myself, nor my attorney, nor anyone else acting on my behalf will call on this provider to testify in court or at any other proceeding, nor will a disclosure of therapy records be requested. • If this provider is required to testify for court, speak with legal counsel, prepare documentation, etc. the fee is $300.00 500.00 an hour plus mileage and expenses incurred. This provider will not testify in divorce custody or mediation. A two hour minimum will be charged.

Divorce and Custody. I understand that this provider is not a custody evaluator and cannot make any recommendations on custody. She can refer me to a list of licensed psychologists who provide custody evaluation if needed. She requires a copy of the current, standing court order showing custodial rights for each parent and/or the parenting agreement that is signed by both parents and the judge at the first intake session before she is able to meet with my child. I understand that she will need to have contact with the parent who has legal custodial decision making for medical issues before she sees my child for evaluation or treatment and will need to obtain written consent for the child to participate in counseling from the legal custodian, and prefers to have contact with both parents prior to seeing my child. Legal Proceedings – I understand that I am being asked to waive the right for this provider to be summoned by subpoena to court. The policy is set in order that this provider can preserve the efficacy ef- ficacy and integrity of my therapeutic process and my relationship with me and my child(ren)me. This provider’s appearance ap- pearance in court can damage the therapist-client relationship and it is her ethical duty to make every reasonable effort to promote the welfare, autonomy, and best interests of her clients. By signing this agreement, I am waiving my right to have this provider subpoenaed and agreeing to not to have her or her records subpoenaed. Initial Court Testimony – I further understand that there may be other conditions (such as a court orderor- der) that may place limits on the therapist’s legal ability to maintain my confidentiality. Due to the fact that the therapeutic process often involves disclosure of many matters which are confidential confi- dential in nature, it is agreed that should there be any legal proceedings neither myself, nor my attorney, nor anyone else acting on my behalf will call on this provider to testify in court or at any other proceeding, nor will a disclosure of therapy records be requested. • If this provider is required to testify for court, speak with legal counsel, prepare documentationdocu- mentation, etc. the fee is $300.00 500.00 an hour plus mileage and expenses incurred. This provider will not testify in divorce custody or mediation. A two hour minimum will be charged.

Divorce and Custody. I understand that this provider is not a custody evaluator and cannot make any recommendations on custody. She can refer me to a list of licensed psychologists who provide custody evaluation if needed. She requires a copy of the current, standing court order showing custodial rights for each parent and/or the parenting agreement that is signed by both parents and the judge at the first intake session before she is able to meet with my child. I understand that she will need to have contact with the parent who has legal custodial decision making for medical issues before she sees my child for evaluation or treatment and will need to obtain written consent for the child to participate in counseling from the legal custodian, and prefers to have contact with both parents prior to seeing my child. Legal Proceedings – I understand that I am being asked to waive the right for this provider to be summoned by subpoena to court. The policy is set in order that this provider can preserve the efficacy and integrity of my therapeutic process and my relationship with me and my child(ren)me. This provider’s appearance in court can damage the therapist-client relationship and it is her ethical duty to make every reasonable effort to promote the welfare, autonomy, and best interests of her clients. By signing this agreement, I am waiving my right to have this provider subpoenaed and agreeing to not to have her or her records subpoenaed. Court Testimony – I further understand that there may be other conditions (such as a court order) that may place limits on the therapist’s legal ability to maintain my confidentiality. Due to the fact that the therapeutic process often involves disclosure of many matters which are confidential in nature, it is agreed that should there be any legal proceedings neither myself, nor my attorney, nor anyone else acting on my behalf will call on this provider to testify in court or at any other proceeding, nor will a disclosure of therapy records be requested. • If this provider is required to testify for court, speak with legal counsel, prepare documentation, etc. the fee is $300.00 500.00 an hour plus mileage and expenses incurred. This provider will not testify in divorce xx- xxxxx custody or mediation. A two hour minimum will be charged. Fees, Charges and Responsibility for Payment – I understand that payment, in the form of cash, check, or credit card, is due after each session. Individual sessions are 45-60 minutes in length depending on whether the session is being billed to insurance or not. Fees are as follows: Psychological evaluations are $250 per hour billed/or negotiated rate: . Psychotherapy is billed at $150 per hour/or negotiated rate: . Forms, letters, and affidavits will incur a $45 per report fee/or negotiated rate: . A fee of $25 will be incurred should my check be returned. I will also be responsible for any expenses incurred to collect unresolved balances as well as a 25% additional fee, and I understand that I may waive my right to confidentiality in the event that the unresolved balance is sent to a collections company or agent. Appointments – Sessions are scheduled directly with my therapist. I am required to give at least a 24 hour no- xxxx to my therapist in advance if I am unable to keep a scheduled appointment, to prevent being billed for the session. I can reach my therapist at 000-000-0000 and leave a voicemail. I will be responsible for the session fee, if less than 24 hours’ notice is given. Please note that insurance companies do not reimburse for missed sessions. I understand that, unless otherwise indicated, insurance claims will not be filed on my behalf, but that I will receive an invoice to send to my insurance company. Unless alternative payment arrangements have been made prior to the delivery of services, I understand that payment is due at the time services are delivered. I un- derstand that psychological testing reports will not be released until payment for the evaluation is made in full. I understand that I will be charged full psychotherapy or psychological testing fees and I agree to pay those fees in the event that I fail to show for an appointment or cancel an appointment with less than twenty-four hours no- xxxx. Repeated late cancellations or failure to show for scheduled appointments may result in my termination as a client. Use of Technology – Individuals may contact their therapist using technological resources. In doing so, they agree to the understanding that cell phone, text, email and fax communication are not guaranteed confidential methods of communication. When used, the client is by choice, relinquishing their rights to confidentiality. If I send an email to my therapist, she will review my email prior to the next session. Texting is allowed for schedul- ing or rescheduling appointments; but no clinical dialogue will be shared via text. You may text at 678-820- 8386. I understand that, although I may engage in the use of social media, this provider is not permitted to friend, follow, or message me via social media outlets due to the nature of her ethics code (APA 2010). In Case of Emergency – I understand that this provider does not provide emergency services. She will make every reasonable effort to return my calls as soon as possible and at least within 48 hours of messages being left during regular business hours. I will receive a card from my provider with all of the ways for contacting her. If I have a mental health emergency, I am encouraged to do one of the following: • Call 911 Go to your nearest emergency room • Xxxxxx County Suicide Hotline Number – 000-000-0000 • Forsyth County Suicide Hotline number – 000-000-0000 Consent – My signature below indicates that I have read, been advised of, and understand the above information and that I consent to receive psychological services under these conditions. I also acknowledge that I have read and understand the HIPAA Georgia Notice Form.

Divorce and Custody. I understand that this provider is not a custody evaluator and cannot make any recommendations on custody. She can refer me to a list of licensed psychologists who Initial provide custody evaluation if needed. She requires a copy of the current, standing court order showing custodial rights for each parent and/or the parenting agreement that is signed by both parents and the judge at the first intake session before she is able to meet with my child. I understand that she will need to have contact with the parent who has legal custodial decision making for medical issues before she sees my child for evaluation or treatment and will need to obtain written consent for the child to participate in counseling from the legal custodian, and prefers to have contact with both parents prior to seeing my child. Legal Proceedings – I understand that I am being asked to waive the right for this provider to be summoned by subpoena to court. The policy is set in order that this provider can preserve the efficacy and integrity of my therapeutic process and my relationship with me and my child(ren). This provider’s appearance in court can damage the therapist-client relationship and it is her ethical duty to make every reasonable effort to promote the welfare, autonomy, and best interests of her clients. By signing this agreement, I am waiving my right to have this provider subpoenaed and agreeing to not to have her or her records subpoenaed. Court Testimony – I further understand that there may be other conditions (such as a court order) that may place limits on the therapist’s legal ability to maintain my confidentiality. Due to the fact that the therapeutic process often involves disclosure of many matters which are confidential in nature, it is agreed that should there be any legal proceedings neither myself, nor my attorney, nor anyone else acting on my behalf will call on this provider to testify in court or at any other proceeding, nor will a disclosure of therapy records be requested. • If this provider is required to testify for court, speak with legal counsel, prepare documentation, etc. the fee is $300.00 500.00 an hour plus mileage and expenses incurred. This provider will not testify in divorce custody or mediation. A two hour minimum will be charged.