Instructions: This form requires at least one parent to sign. Children 13 years of age or older should sign if they are in the custody of the signing parent. If both parents are present, both may sign together and submit this form. If parents live seperately, each parent will submit an application on their own.

A. Professional Qualifications:

The clinicians at Counseling West Seattle have Master's or Doctoral Degrees and are licensed in the state of Washington. We have ample experience working with children, adolescents, and families of divorce. We are highly familiar with, and committed to following, all court orders associated with the Reunification process.

B. Reunification Policies and Fees:

Reunification Counseling for families coping with divorce will be tailored to meet the children's and families' specific needs and circumstances, and to be consistent with the terms of the parenting plan and/or any other court orders in force. Reunification Counseling sessions may include the parents individually, the parents with the children, the children individually, other involved family members as appropriate, and in a few cases, with the parents together. The number and sequential order of sessions and other interventions is to be determined by the reunification counselor, tailored to the family circumstances, and consistent with any applicable court orders.

Our fee for all services; including in-person meeting, telephone interviews and consultations, and review and preparation of document and correspondence is $200 per hour. Travel is billed at $50 per hour or as negotiated. We require an initial deposit (a retainer) that is based on applicable court orders and circumstances of the specific case. The amount of the initial deposit represents the therapist's best estimate of the minimum hours of service they will provide. Any funds remaining on deposit after services are completed or discontinued, will be promptly refunded. The portion of responsibility, each parent has for payment must be agreed upon and/or consistent with any court orders in the specific case. Except in cases of emergency, any missed appointments that are not canceled at least 24 hours in advance will be billed for a full hour. Fees not covered by the initial deposit must be paid prior to or at the time of service, and in this regard, we may require a second retainer.

C. Insurance Coverage:

We do not accept private insurance for Reunification Counseling. However, we are happy to provide an Invoice of payments received and services rendered should one wish to pursue reimbursement independently.

D. Confidentiality Waiver:

Reunification Counseling services may or may not be confidential, depending upon the court orders that apply to these services. The therapist will always use discretion regarding information specific to each parent's household, as well as other boundaries that are deemed clinically appropriate. However, applicable court orders may require the Reunification Counselor to provide information to the court and the other parent and their counsel of record about the children's wellbeing and implementation of the parenting plan.

Parent/Guardian 1 Signature

Electronic Signatures: The Parties agree that any form of electronic signature, including but not limited to signatures via facsimile, scanning, or electronic mail, may substitute for the original signature and shall have the same legal effect as the original signature.

By signing below, parties are acknowledging the electronic signatures clause and are agreeing to the terms, conditions, and disclosures as specified in this document. ("Disclosure and Agreement Statement").

Parent/Guardian 2 Signature

Electronic Signatures: The Parties agree that any form of electronic signature, including but not limited to signatures via facsimile, scanning, or electronic mail, may substitute for the original signature and shall have the same legal effect as the original signature.

By signing below, parties are acknowledging the electronic signatures clause and are agreeing to the terms, conditions, and disclosures as specified in this document. ("Disclosure and Agreement Statement").

Child 1 Signature

Child 2 Signature