Client Intake & Service Agreement

Est. 2010
Client Intake & Service Agreement
"Improving Child Outcomes When Parents Separate"
Phone: 855-862-9236 | Email: info@thetobycenter.org | Website: www.thetobycenter.org

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Family Ties 9th Circuit - When Assigned
Agency
Family Court
Client Name/Case Number
Date of Intake

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2 digit month, 2 digit day, 4 digit yearDate
Our Promise and Mission
At the Toby Center, we believe "The Best Parent is BOTH Parents". We are committed to helping your family navigate this journey through safe and meaningful connection. When children are supported by the healthy presence of both parents, they thrive, achieving better stability and lasting happiness. To ensure structure and legal compliance, we strictly follow all Court Orders. It is our professional duty to report on compliance and visitation progress to the court to ensure the continued safety of your children.
Service Agreement Instructions
- Legal Review: This is a legal document requiring your review and written completion.
- Acknowledgement: All sections must be initialed, and a final signature affixed to confirm agreement.
- Completion: Entries may be completed online or by hand and must include the date.
- Section Review: By initialing, you acknowledge that you have read and agree to abide by the specific protocols outlined.
Part 1: Rules & Regulations
Safety Protocols:
- o Neutrality: The Center remains neutral, focusing solely on the child's well-being.
- o Smoking and Vaping: No smoking or vaping is permitted during the visitation sessions.
- o Authorized Attendance: Only individuals named in the court order or joint agreement may attend.
- o Prohibited Items: No weapons, animals, or pets are permitted.
- o Impairment Policy: Anyone arriving impaired by drugs or alcohol may face immediate suspension of the visit.
- o Use of Cell Phones: No use of cell phones is permitted, unless for photos or for shared games with approval by the Field Monitor.
- o No opened food items: Food is permitted but only if commercially purchased and unopened previously. Food limitations for health and well being must be followed. Contact Field Monitor in advance if bringing food for holiday, birthday, or other celebration.
Arrival & Departure (Staggered Parking Policy):
- o Visiting Parent: Arrive 15 minutes early and enter the building immediately.
- o Custodial Parent: Arrive exactly at the scheduled start time; the monitor will meet you at your car to escort the children inside.
- o Separation: The custodial parent must leave the premises and the parking area immediately and remain out of sight until the scheduled return.

o Mandatory Safety: The monitor will wait with the visiting parent inside after the visit to ensure the custodial parent has cleared the area.
Visitation Conduct:
O Communication: All conversations must be audible; no whispering is allowed.
o Prohibited Topics: Court cases, legal disputes, or unsupervised visit requests may not be discussed in the child's presence.
O Positive Parenting: No corporal punishment, profanity, or degrading discipline is permitted.
o Cameras & Electronics: All devices (phones, tablets, etc.) must be turned off and put away. Pictures and Videos are up to the discretion of the monitor. In addition, it must be stated no pictures or videos can be posted on Social Media. If this occurs, the privilege will be taken away.
o Additional Comments
Client Initials:
Date:

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2 digit month, 2 digit day, 4 digit yearDate
Part 2: Child Information & Medication
Medication Protocol:
o Policy: Staff will not administer medication under any circumstances.
o Coordination: No parent may administer medication without prior coordination with staff and written authorization from the other guardian.
o Emergencies: The Center will contact emergency services first; parents assume all liability for costs.
Well-being History:
o Trauma-Informed Care: Please indicate if the child has witnessed or been a victim of domestic violence.
o Restrictions: Detail any food, meal, or allergy restrictions.
o Interests: Please share with Family Monitor the child's favorite activities, toys, and specific fears.
o Additional Comments
Client Initials:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Part 3: Service Contract & Financial Agreement
Payments:
2

o Methods: Online only via the Client Payment Portal using debit or credit cards; no cash or checks. Please use your respective State payment portal. Paid receipts constitutes proof of payment and need to be provided to the field monitor at least 24 hours in advance of session.
o Third-Party: Third parties may pay if the client's name and relationship are clearly noted.
o Fees: Supervised Visitation Intake fee is $95 per parent is non-refundable. Therapeutic Visitation Intake Fee is $120 per parent and non-refundable. Child Reunification Intake Fees are $150 per parent and non-refundable. Visitation fees are on a sliding scale with proof of income. (Fees are subject to change)
Shared Payment Responsibility

a) Split Fee Payments: If fees are shared per a court order or joint agreement, each party must complete the Joint Agreement registration form and agrees to be responsible for paying their specific portion via the Toby Center website at least 24 hours in advance.

b) Independent Accountability: Each parent must manage their own payments through the portal; third-party payers must include the client's name and relationship in the "Note" section to ensure proper credit.

c) Impact of Non-Payment: If any portion of a shared fee is not paid by the deadline (24 hours prior, or Friday at noon for weekends), the session may be suspended or canceled.
o Deadlines: Fees must be paid 24 hours in advance. Weekend sessions must be paid by Friday at noon.
o Cancellation: Failure to provide 24-hour notice of cancellation of a confirmed visitation results in a forfeiture of the full fee.
o Non-Compliance & Malicious Intent: If a visit is canceled due to documented non-compliance or intentional interference with the court-ordered schedule, the Court will be notified.
Documentation, Records & Subpoenas:
o Records: The Toby Center is not a records custodian. All records must be obtained directly from the independent visitation monitor.
o Court Contact: As part of our professional duty, the Toby Center maintains contact with the court to report on compliance, visitation progress, and the well-being of the children.
o Subpoenas: Subpoenas for testimony must be delivered to the Visitation Monitor/ Therapist directly and may require a prepaid fee determined by the monitor.
o Payment History: Financial records (Payment History) may be requested of CFO who will provide them upon flat fee of $99, payable on Toby Center payment portal.
o Additional Payment Comments
Client Initials:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
** In addition to your New Client Registration forms, please be sure we have a copy of a) any Court Order for visitation; b) knowledge of any restraining order (i.e., TRO), and c) photo ID of any parties transporting the children.
Execution of Agreement
By signing below, I acknowledge that I have read the rules, understand my rights and responsibilities, and agree to comply with this contract.
Ed. 4-17-26 (5)
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Print Name:
Date:
Signature:
Witness (if present)
Ed. 4-17-26 (5)
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Should be Empty:

Client Intake & Service Agreement

"Improving Child Outcomes When Parents Separate"

Our Promise and Mission

Service Agreement Instructions

Part 1: Rules & Regulations

Safety Protocols:

Arrival & Departure (Staggered Parking Policy):

Visitation Conduct:

Part 2: Child Information & Medication

Medication Protocol:

Well-being History:

Part 3: Service Contract & Financial Agreement

Documentation, Records & Subpoenas:

Execution of Agreement