PTC Enrollment Form

Ellis Evaluation & Consulting Services

MESHA ELLIS, PH.D.
PTC Enrollment Form
I am registering for the coparenting class beginning on:
Your Name
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.

Children's and Other Parent Information
Child 1 Name

First NameLast Name
Age
Child 2 Name

First NameLast Name
Age
Child 3 Name

First NameLast Name
Age
Children's Other Parent Name
Phone No.
Format: (000) 000-0000.
Full Name of Your Current Spouse or Significant Othe:r

Custody/Visitation Arrangement in Effect Now:
Your Parenting Times:
Other Parent's Parenting Times:
Court Jurisdiction

Other (Specify)
If ordered by court, was the order for:
Do you have an upcoming court date:
If yes, when?
Name of your Attorney
City
Phone
Format: (000) 000-0000.
Attorney of Other Parent
City (if known)
Phone
Format: (000) 000-0000.
Children's Minor Counsel/Guardian ad Litem (if any)
Phone
Format: (000) 000-0000.
Participating in PTC does not constitute a contract for a psychological evaluation or counseling, or issuance of a written report. Services such as counseling are provided by Ellis Evaluation & Consulting Services, strictly on a contractual basis. In any capacity, whether that of education or counseling, the staff of Ellis Evaluation & Consulting Services are bound legally and ethically to respect the confidentiality of its clients. For thisreason, Ellis Evaluations & Consulting Services cannot and will not, unless having on hand a signed Authorization to do so, release information verbally or in writing - including whether or not a given individual has taken part in activities offered by Ellis Evaluation & Consulting Services. Confidentially can and will be suspended, however, per provisions of California law, if the staff of Ellis Evaluation & Consulting Services determines in any direct dealings with its clients that (a) an individual is a serious danger to self or others, or (b) there is a reasonable basis for suspecting child abuse and/or neglect. I have read the above, and consent to avail myself of services offered by Ellis Evaluation & Consulting Services.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

My Products

Parents Together for Child Co-Parenting Class

The Parents Together for Children (PTC) Program is a 12 hour, research informed skills building class for separated, divorcing, and never married parents. Classes are held virtually over the course of 6 weekly, two-hour sessions. The virtual sessions are hosted using a HIPAA compliant version of Zoom.

$400.00 Indicate Class Cohort Chosen

Total

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Ellis Evaluation & Consulting Services

PTC Enrollment Form

Children's and Other Parent Information

Custody/Visitation Arrangement in Effect Now:

My Products

Payment Methods