Agreements and Disclosures (1 Year Contract for Alumni)

Agreements*

I authorize the Solutions Parenting Support, it’s employee’s and Independent Contractors to email any correspondence regarding my treatment, satisfaction with treatment, updates about my treatment and educational programs during and after the completion of my treatment to my provided email address.
I authorize the Solutions Parenting Support, it’s employee’s and Independent Contractors to collaborate with outside referral sources and outpatient therapists as documented onlyon the release of information form that I provide.

Disclosures*

I understand Solutions Parenting Support, it’s employee’s 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:

Total charge $980
Services Included 1 scheduled parent coaching session per month for 1 year total.

Additional Comments and Special Arrangements*

Please check the boxes to acknowledge the following terms:

The agreed upon rate will be paid in full and will be due prior to the initial monthly session.

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*

Phone

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