1. Please fax or email the following items for the Intake Meeting:
2. Review Case History and needs with parents:
This includes discussions of why services are needed, what services we can provide, and the family dynamics that are important for us to know.
3. Review forms and policies:
THE THERAPEUTIC SOLUTION staff will review each form explaining and elaborating on the meaning that needs to be signed and completed by the parent. Please have your forms completed when you arrive to expedite the process.
4. Establish a time-sharing plan:
Forms: Intake Packet, Release of Information, Fee Agreement, Child Information Papers, Court Papers, Emergency Procedures, Child Health and Allergies, Personal History and Policies and Procedures
A plan for the first appointment is discussed and scheduled that includes the date and time for the visitation, persons permitted at the visit, and any possible activities planned at the visit.
5. Your child is welcome to attend a separate meeting
To become introduced to the location and staff where they will participate in visitation. The intake meeting is not appropriate for your children to participate. If a family member would like to bring them at the end of the meeting for the last 5 -10 minutes that is also an option.
Intake Application
Supervised Visitation and Exchange
The Therapeutic Solution
Please supply a copy.
4. Have you and/ or the other party ever been convicted of a felony or misdemeanor?
Type of Abuse:
6. Have there ever been charges filed against you or the other party for physical abuse?
7. Do you or the other party own any weapons?
MEDICAL INFORMATION FORM
This form is to be completed when children need medication or have a special dietary requirement that might arise during visitation. Please complete a separate form for each child.
Medical Information
Please write additional medications on a separate sheet
Food Allergies and Special Dietary Needs
You (Custodial Parent) are required to bring any EPI pen or other antidotes to visitation sessions and leave it with us for the duration of the visit for the safety of your child. Forgetting the EPI pen or antidote will result in canceling the visit and the fee will be charged in full to the Custodial parent.
Weather permitting, we may have supervised visits outside, please provide, hat, sunscreen, bug repellant is you wish them used during the visit
I authorize THE THERAPEUTIC SOLUTION to call for emergency medical care for any child since we cannot transport and attempt to notify me at the following number as soon as possible.
During Supervised Visits, bottle-fed children will be provided at least one prepared bottle for the visit by the Custodial parent.
ADDITIONAL INFORMATION & AGREEMENT
Health Information
3. Substance Abuse History by either party:
History of drinking alcoholic beverages
History of non-prescription street drugs:
History of prescription drugs:
Do you believe that there is a problem currently with drugs or alcohol?
Custody and Visitation Arrangement
9. What is the understanding of the reason why you were referred to The Therapeutic Solution (mark all that apply)
I agree to participate in supervised visitation which includes following policies and rules to create a safe environment for parent–child interaction. I will follow these rules and if I am not certain of a rule I will seek clarification before acting upon it. I recognize that all interactions are written down and reported to the Court, these are observations of my behavior without judgment or prejudice.
I certify that the information given above is true and complete and I understand that misrepresentation and/or withholding of information will result in the rejection of this application or my dismissal as a client if discovered after service begins. I understand the court will be notified of this dismissal and that this may affect the visitation or custody of my children.
I understand that THE THERAPEUTIC SOLUTION can make no promises or guarantees relating to visitation or court matters, my client status may be suspended any time that I or any part of my family/friends become unsafe for the facilities and/or staff The Therapeutic Solution. I understand that any termination as a client will be documented and that this documentation may be presented to the court.
Fees and Fee Agreement
More than 17 minutes late $ 35, with no further visits scheduled until the case is referred back to court. The fees above are based on communication that is EMAIL; phone communications are charged at the full fee and not the discounted email fee. You will need to add a $10 per visit for phone-based communications if you choose to not use the email communications
Payment Responsibility
Court-ordered families are assigned payment responsibility by the court. Other referring agencies may indicate in writing who will be responsible for payment. If the referring agency does not indicate who will be responsible for payment, THE THERAPEUTIC SOLUTION will assign financial responsibility. Service will not be provided until a fee agreement is signed by both parties and the initial payment is received.
Cancellations
All cancellations must be made at least 48 hours in advance of a scheduled appointment or visitation. Parents are not charged if proper notice is given; this is expected during business or supervision hours. The party who cancels outside of the time frame will be charged the full visitation fee, regardless of which parent is responsible for visitation cost.
No Show
A party who fails to arrive for an appointment and has not notified the Center will be charged the entire amount of the service. Rescheduling of visits will depend on the Center’s availability and cannot be guaranteed. Two cancellations without notification will result in termination of services and notice will be sent to the referring agency. Services may be suspended or terminated due to non-payment.
Court Testimony
A retainer fee of $1000 is required in advance to the party issuing the subpoena, with an additional $125 per hour fee for waiting time in court and preparation, with a minimum of two hours of preparation for court. It is understood that no further information is generally available or useful outside of the Observation Monitoring Sheets which are prepared and submitted to the Court, creating no need for court testimony since Therapeutic Solution makes neither recommendations nor interpretations of the visit.
All fees can be paid online at our website www.tts-nv.com or by cash (via cashapp), cashier’s check, money order, or Visa/MasterCard. Payments are paid in advance of the next visit. Payment for the next visit is made at the time of the current visitation/exchange. Any charge cards being used will need to be in your possession and a separate form filled out for ongoing use for the card for regular billing.
Payment for Visits
All fees are required one week in advance of the visit. We believe this is thoughtful to the children and the other parents in scheduling. It also provides both parents with the advance planning necessary to save money and also to plan the visit. I am showing my commitment to visiting with my children by consistently paying for my visits in advance to regularly and routinely have contact with them.
My Financial Obligation
I agree to make all payments for all services rendered and all services I default on by being late to visitation, late cancellation, no-shows, penalty fees, or requests for documents. I am liable for all additional court costs, attorney fees, and interest charged at the rate of 35% annually for balances due to THE THERAPEUTIC SOLUTION for these services. I will be terminated from service for non-payment and I will only be able to resume visits once I am paid in full. This also may necessitate a larger payment for future visits on my part paying for 2 or more visits instead of one in advance.
My signature indicates I understand the fees on these pages and agree to pay them.
I may withdraw from services with THE THERAPEUTIC SOLUTION at any point by giving written notice that I no longer wish to participate in supervised visitation and am formally canceling my visits and withdrawing from their services. Until I do this I am obligated for all services I have arranged and agreed upon.
