Custody Contract

Custody Contract

Please note if there is joint legal custody, both parents will need to complete this form.
PSYCARE POLICIES REGARDING JOINT CUSTODY

1. PsyCare providers do not conduct custody evaluations or give custody opinions.
2. If parents have joint legal and medical custody, both must agree on the treatment plan for the children to be treated by PsyCare.
3. In court custody matters, children’s records will be released only by an order by the judge or to an attorney appointed by the court to represent the child. In court matters, children own privilege to their records.
4. Records will not be given to parents. Such violation of confidentiality would destroy the therapeutic relationship.
5. All parents, even non-custodial parents have a right to know how the child is doing in therapy.
6. If adversarial conditions between the divorced parents are contaminating the child’s therapy and causing the child additional guilt, anxiety, and stress, the PsyCare provider will recommend termination of therapy until the parents attend Parent’s Turn, and/or the children attend Kid’s Turn, a community service to aid children of divorce.
7. Therapist reports: A minimum fee of $50 will be charged for any letters, reports or treatment summaries requested by either custodial parent. Physician reports: The fee charged will be at the discretion of the physician. Each custodial parent will be provided with a copy of the document. The requesting parent shall make payment for clinical documents(s) at the time of request.*

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Name of Person Completing this Form*

First NameLast Name
DOB for Person Completing this Form*

MonthDayYear
Date
Phone Number for Person Completing this Form*

Area CodePhone Number
Child's Full Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
I give my consent for my child to be treated by the following (check one box only).*

Therapist OnlyMD OnlyBoth Therapist and MD
Signature of parent to confirm consent for specific level of treatment. *Note: Custodial parents must agree on level of care. In the event that one custodial parent revokes consent for treatment with a therapist or a psychiatrist (MD), each parent must sign a new PsyCare Custody Contract for child to resume care.*

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A) Transportation will be arranged by the parent who the child is residing with on the date of scheduled appointment and/or agreed upon mutually between parents.
B) The parent scheduling the appointment will be responsible for canceling appointments within 24 hours and/or paying any associated late cancellation fees. Parents agree to communicate with each other when cancelling
or rescheduling appointments.
C) Copays/Deductibles are to be paid at the time of session, please list only one (1) parent who will be financially responsible for all balances even if both parents are legally responsible for payment.
D) PsyCare does NOT do mediation or get involved with parents financial arrangements.
Name of financially responsible parent (one name only, must be the same on both forms submitted by each parent).

First NameLast Name
Address of the FInancially Responsible Parent*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth of the Financially Responsible Parent*

MonthDayYear
Date
By signing below, I have read and agree to the above policies and to A through D.*

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Name of Signer*

First NameLast Name
Today's Date*

MonthDayYear
Date
Should be Empty: