The Center for Families, LLC s1

The Center 4 Families, LLC

27 Gamecock Ave. Suite #202 Charleston, SC 29407 Helen Elliott Wheeler, M.Ed. LPC (843) 763-5837; Fax (803)753-0134 [email protected] Client Information for Co-Parent Coaching/Counseling

Client’s Name______Date______

Address ______City, State, Zip______

Home Phone ______Daytime phone______Cell ______

Email ______Fax ______

Emergency Contact Information: Name______Phone ______

1.Do you have an attorney? Y N If so what is his/her contact information?

Attorney’s name ______Address ______

Phone number ______Cell ______Fax ______

Email ______

2. Is there a Guardian ad Litem in place for the children? Y N If so, what is his/her contact information.

Name ______Address______

Email ______

3. Has there been any other counselor involved (with you/ or your child[ren])at any time? Y N If so, what is his/her contact information Name______

Address______Phone number ______

Cell ______Fax ______Email ______

Do I have permission to contact him/her? Y N Please sign ______

Children’s names Age Grade School Live with you? ______

______

4. Do the children have a counselor? Y N If so, please provide the contact information

Phone number ______Cell ______Fax ______Email ______

5. Is there a school guidance counselor involved with the children? Y N If so, please provide the contact information

School Phone number ______Fax ______

Email ______

6. Do the children have a pediatrician or family physician involved? Y N If so, please provide the contact information

Email ______

7. Is there a baby sitter/childcare worker or facility involved with your child(ren)? Y N If so, please provide the contact information

Email ______

I understand that the fees for Co-Parent Counseling or Co-Parent Coaching are $100.00 per hour, payable at the time of the session. The Center for Families is not set up to do billing and co-parent coaching is not covered by insurance. If the parents have family counseling covered by their health insurance, under some circumstances the fees might be billable to that insurance. Please note that if the couple is no longer married or has never been married, these sessions will not be considered for family counseling for the purpose of filing insurance. Fees are usually split equally between the parents. I understand that this process is not confidential and information will be shared with the other parent. It is anticipated that signing this form constitutes permission to release information to and/or receive information from these individuals:  Attorney,  Guardian ad Litem  Individual and/or child(ren)’s counselor  School guidance counselor  Baby sitter/childcare workers  Family physician/Pediatrician Sessions are usually 90 minutes long. If one parent is a “No Show” or cancels at the last minute without sufficient notice (typically 24 hours), that parent will be charged the entire session fee and no further sessions will be scheduled until the fee is paid. For extensive e- mail communication and/or for frequent phone conversations, the charges will be prorated on the above scale in 15 minute increments and are payable at the next session. It will also be necessary to have on file a Consent form to utilize email communication. If the fees are not paid promptly, no further appointments will be made and your attorney will be contacted. Understand that if you subpoena me to appear in court, I will make every effort to avoid testifying. At times, the Judge rules that his/her need to have the information I might provide supersedes your right to privacy and I will be ordered to testify. In addition, if I testify in court, it is often necessary for me to be discharged from the case afterwards. In addition, you will incur the hourly charge of $200.00 per hour (minimum charge for court appearance is $400.00) payable immediately.

By signing, I acknowledge reading the above information ______

Therapist signature______Date______

Is there a court order in place? Y N If yes, please provide it today or fax one to me