Intake Agenda and Checklist

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.

THE THERAPEUTIC SOLUTION

Intake Application

Supervised Visitation and Exchange

Supervised Visitation and Exchange

Supervised Visitation and Exchange

LEGAL INFORMATION

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

The Therapeutic Solution

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

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)

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