FPS Custody Intake Packet

Client Information
Full Name*
Preferred Name (Goes By)*
Date of Birth*

MonthDayYear
Date
Marital Status*
Spouse or Partner's Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Employer*
Work Schedule*
Please list any other agencies with which you receive services:*
Therapy, parenting classes, or anything else you feel is relevant for us to understand what you are working on. Examples: Clark Center, Ozark Center, Parents As Teachers.
How did you hear about us?*
Limits of Confidentiality
Contents of all appointments are considered to be confidential, verbal information and written records cannot be shared without the written consent of the client or the client's legal guardian. Noted exceptions are as follows:

Duty to Warn and Protect: When a client discloses intentions or a plan to harm another person, the mandated reporter is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the mandated reporter is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Abuse of Children and Vulnerable Adults: If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mandated reporter is required to report this information to the appropriate social service and/or legal authorities.

Minors/Guardianship: Parents or legal guardians of non-emancipated minor clients have the right to access the clients' records.

Insurance Providers (when applicable): Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to: types of service, dates/times of service, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries.

I agree to the above limits of confidentiality and understand the responsibilities of the mandated reporter.
Today's Date*

MonthDayYear
Date
Client Signature*
Attendance Policy
The client understands that consistent attendance and participation in scheduled Parent Aide sessions is expected in order to support progress and maintain the effectiveness of services related to custody matters. The client agrees to confirm scheduled appointments by noon on the day prior to the appointment and acknowledges responsibility to attend all scheduled sessions or notify the agency at least 24 hours in advance if unable to attend. Arriving more than 15 minutes late may result in the session being canceled.
Initial your Agreement here:*
By signing this document I am agreeing to this attendance policy and will abide by the above mentioned guidelines of confirming appointments. If my appointment is not confirmed, I understand that it may then be cancelled.
Today's Date*

MonthDayYear
Date
Client Signature*
AUTHORIZATION TO RELEASE/EXCHANGE CONFIDENTIAL INFORMATION

This authorization permits the exchange of information related to the case among authorized and legally involved parties. Communication may occur through shared methods, including but not limited to group email correspondence, through which case notes, updates, and other relevant information may be distributed to authorized parties simultaneously to support coordination, case planning, and informed decision-making.
Petitioner:*

First NameLast Name
Petitioner's Attorney:

First NameLast Name
Respondent:*

First NameLast Name
Respondent's Attorney:

First NameLast Name
Guardian Ad Litem:

First NameLast Name
Today's Date*

MonthDayYear
Date
Signature of Client or Guardian*
Parent Aide Role
The role of the Parent Aide in custody cases is to support the development of safe, stable, and healthy parenting dynamics that promote the best interests of the child. Services focus on encouraging constructive communication, strengthening trust between parents and children, and supporting cooperative co-parenting when applicable. The Parent Aide may observe parent-child interactions and provide guidance on healthy parenting practices, child development, and age-appropriate expectations. The overall goal is to promote positive family relationships and support a parenting environment that prioritizes the child’s safety, stability, and well-being.
Client Expectations
I acknowledge that I have read and received the Parent Aide Role handout and agree to the following.
Client will provide all necessary items for child(ren) including but not limited to; diapers, wipes, changes of clothes, beverage, meal and/or snack, toys and/or activities.
Initial your Agreement here:*
Client understands that the visits are intervention-based meaning that the Parent Aide will be offering feedback from evidence-based curriculum to assist the parent in positively furthering their parenting techniques.
Initial your Agreement here:*
Client understands that corporal punishment is not allowed in any circumstance and if corporal punishment is used or suspected of the visit will be immediately terminated.
Initial your Agreement here:*
Client understands that client and child(ren) must stay within earshot and eyesight of Parent Aide at all times.
Initial your Agreement here:*
Client understands that Parent Aide sessions must remain child-focused and that discussion of the custody case or negative comments about any other custodial party are not permitted and may be redirected by the Parent Aide.
Initial your Agreement here:*
Client understands that payment must be received prior to services being provided, and failure to submit payment in advance may result in cancellation of the scheduled service.
Initial your Agreement here:*
Client understands that they must comply with all applicable court orders, including but not limited to custody orders, no-contact orders, and any other court-imposed requirements, while participating in Parent Aide services.
Initial your Agreement here:*
Today's Date*

MonthDayYear
Date
Client Signature*
Pest Disclosure Agreement
If your home has, or you become aware of, bedbugs, fleas, cockroaches, lice or similar pests at any time during services, you are required to:
● Inform your provider immediately.
● Work with your provider to create a plan to reduce the risk of spreading pests.

This plan may include:
● Holding visits outdoors or in a neutral public setting.
● Wearing clean, freshly laundered clothes for visits.
● Avoiding transport of bags or personal items between locations.
● Be open to using visit time to support treatment and prevent spreading.

If pests (such as bedbugs, fleas, or cockroaches) are observed during a visit, or if it
becomes clear that the agreed-upon plan is not being followed, the visit may need to be paused to ensure everyone's health and safety. Services can continue once the situation has been addressed and an updated plan is in place.

We understand that these situations can be stressful, and our goal is to support you
through them. We’ll stay in contact and work with you to find safe, practical solutions that keep your family connected to services.

I have received, read, and understand the Pest Disclosure Agreement regarding
pests such as bedbugs, lice, fleas, and cockroaches, and agree to follow the
guidelines during services.
Today's Date*

MonthDayYear
Date
Client Signature*
Should be Empty:

Client Information

Limits of Confidentiality

Attendance Policy

AUTHORIZATION TO RELEASE/EXCHANGE CONFIDENTIAL INFORMATION

Parent Aide Role

Client Expectations

Pest Disclosure Agreement