Adoption Advisement

North Texas Family Services

Lauren Gordon, LCSW

8301 Lakeview Parkway Suite 111-131

Rowlett, TX 75088

214.675.3978

www.ntxfamilyservices.com

Please check each box and sign at the bottom.

The full amount is due at the time noted in the invoice, unless we have specifically discussed otherwise. The cost of the adoption study ranges from $1500- $1750.The fees for an adoption social study are nonrefundable.timeframe for completion begins the day of the initial home visit.If I have selected an expedited social study, I acknowledge the timeframe for completion begins the day of the initial home visit.No expediting fees will be refunded if requested documents are not provided within 30 days of the initial home visitAll studies and post adoption visits include mileage within 50 miles from the mailing address. A mileage rate of $.65 will be charged when the destination is more than 50 miles from the mailing address. If requested, the fee will be added to the invoice.Post adoption visits, if needed through an adoption agency, ICPC, or for the purpose of a follow up, are scheduled with the social worker and the family and must include at least three adoption visits in a 6 monthThe social worker reserves the right to increase the number of post adoption visits or schedule follow up visits, at an additional charge of $500 each, to insure the safety and wellbeing of the placed adopted child or children.Payment does not guarantee an approved social study.I recognize this social study will involve collecting a social history for all adults in the household, conducting interviews with verbal children, and touring the home environment. I also acknowledge that some questions may feel quite personal, but they are necessary to obtain more detailed information. Not providing this information could lead to delays in completing my social study, necessitate additional home visits, or even result in the denial of the study.I agree to disclose any information regarding past CPS and/or criminal history honestly. Additionally, I release the social worker from any liability for negligence should I fail to provide this information.

Contacting the Evaluator:

The evaluator may be reached via telephone calls, text messages, and emails. Communication may also occur in writing to the mailing address listed above.

Services Not Provided:

I understand and acknowledge the evaluator is not providing, nor am I requesting, therapy, counseling or any form of treatment. Should these services be requested during the course of the evaluation, appropriate referrals and recommendations will be provided.I understand the evaluator is not providing mediation, parent facilitating, or other services outside the scope of an adoption social study.I understand the evaluator is not my attorney and any questions pertaining to legal matters, should be directed to my attorney.

Professional Practice Statements

For the purpose of reporting violations of licensing rules or regulations, the Texas State Board of Social Workers Examiners can be contacted by mail at Complaints Management and Investigative Section P.O. Box 141369Austin, Texas 78714-1369 and by telephone, 1.800.942.5540.er.I understand the evaluator is the custodian of records. The evaluator reserves the right to designate another person as the custodian of records in case of death or incapacitation.For the purpose of reporting, the license number can be requested through the social work

Insurance Coverage

I understand none of these services are covered by insurance.I understand this is not therapy, nor can it be billed as therapy.

Release of Information:

I have been informed and I understand any communication or statements made by me or the children will NOT be privileged or confidential.I understand any information provided to the court may become public.Further I understand the evaluator may be required to disclose situations where clients may be a danger to themselves or others; abuse, neglect or exploitation of a child, elderly, or disabled person, or as otherwise required by law.

I have been provided a copy of this contract and invoice and fully agree to the terms listed.

Parent 1 Printed Name

Date

Signature

Parent 2 Printed Name

Date

Signature