Breakthrough Parenting: Co-Parenting High Conflict Focused Enrollment & Consent for Services Form. without the other parent

Consent for Services

When you enroll into the classes at Abundance Guidance Center, you are to pay an intake fee and it is non-refundable. Please make sure you are aware of needing the classes you are enrolling for, once the enrollment forms have been completed, a letter of enrollment has been provided, that justifies the enrollment fee charge. Even if letter of enrollment was not shown to the court there is NO REFUND.

You agree the following:

I am responsible in paying the weekly fee before each class I have enrolled. I am also responsible in attending the classes as scheduled by arriving on time. I understand that I have the right to refuse or discontinue any services. In cases where the classes have been ordered by the court I am still able to refuse to participate in the recommended classes, but social workers, probation, or parol officer will be informed of my unsuccesfful completion. I am also aware that once ending services a letter of completion will not be provided to me.

If at any time a client’s becomes disrespectful in any way during session or group he/she will be asked to leave and terminate services. This is for the safety of the the group members.

The following are rules I choose to follow during my enrollment at Abundance Guidance Center:

Services at Abundance Guidance Center is NOT a non-profit agency that provides parenting classes, anger management for adults, children, and teens, co-parenting high conflict focused classes, and Wellness Program. The center runs and stands from the clients who enroll and attend the classes. Abundance Guidance Center is a fee based center and there are no free classes. Resources are available for those in need. *Abundance Guidance Center does NOT attend court to testify against any clients or external parties. Abundance Guidance Center does NOT provide any other letters besides the letter of enrollment, progress letter (brief letter), and letter of completion. Abundance Guidance Center is NOT responsible with any decisions a client makes during and after the classes the client has taken.

Co-Parenting High Conflict Focused Attending Alone

Please provide correct contact information as you will be contacted via email, text, and/pr by telephone with any questions we may have.

First Name *

Last Name *

Date of Birth * +

Gender *

Female	Male
Other: She, He, They

State ID or Dirvers Lic. *

Address *

City *

Zip *

Phone *

Do you agree in accepting text messages? *

Yes

Email Address. PLEASE make sure you review the correct email address. If you do not provide an acurate email address you will not be notified for your upcoming classes. *

Do you have any health problems the instructor needs to know about? ex: Seizures, Diabetes, Low Blood Pressure ect. *

Emergency Contact First Name *

Last Name *

Phone *

Information of your children

Child 1 First & Last Name *

Date of Birth * +

Child 2 First & Last Name

Date of Birth +

Child 3 First & Last Name

Date of Birth +

Additional children please list first and last name:

Other Parent's Information

First & Last Name *

Does your court order state to do the co-parenting sessions separately? * Please make sure you are mandated to do the sessions separatelyto avoid doing the sessions again and paying again for the co-parenting sessions. *

Yes my order states to do the sessions separately

I am not sure (please confirm before completing this registration form)

MINORS COUNSEL

Do you have a minors counsel assigned to your case? *

Yes

I don't know

Minors Counsel First and Last Name

Minors Counsel Telephone Number

Consent for Services

Confidentiality

Confidentiality: Clients personal information, sharing’s during group, and sessions are confidential. Abundance Guidance Center is not responsible of another clients sharing group information. Clients are encouraged to notify the center if they are aware of any broken confidentiality to be able to address the issue if both parties are still attending any information to an outside party. If you choose to recieve texts you are giving us permission to contact you via text with class or attendance information. *

I agree and accept

Mandated Reporter

Mandated Reporter: Abundance Guidance Center must report any physical, emotional, psychological, and neglect abuse towards minors and seniors. Facilitator will inform families of any report being made as it is to be courteous as mandating reports do not have to inform families but, Abundance Guidance Center feels families should be aware. *

I agree and understand facilitators mandated responsibility.

Virtual Class Rules

Online Virtual Group Rules: 1. You must be in your home location and if you will be in your car you must provide location of where you are located for safety purposes and license plate number. Must be in a quite non distracting environment. Please no laying on the bed nor multitasking during sessions. 2. You are not to drive and be in the session for your safety. 3. All payments must be made before session via Zelle, or Venmo 4. It is important to not miss classes as any missed will be noted on your letter. You will start over no matter how many classes you have left if you fail to miss more than one class. You must call 24 hrs in advance to inform of any emergencies with proof (this is only for court ordered and volunteer who will eventually provide certificate to court) Please note additional rules may be added without notice to help the group run smooth. I understand that I must be at home during classes, not laying in bed, not walking around the house while in class, not in a car and must be present and focused during the class to avoid being removed from the class. *

I agree and accept to follow the virtual seession/class rules.

Payment

Payments: Class fee must be paid before sessions/group begins. Payment can be paid in advance. You will not be given access to enter the class if payment has not been made. No refunds for enrollment and session/class fees. You can pay via Zelle using 562-639-2734 under Amapola Ramirez *

I agree to payment policy

Attendance & Punctuality

Attendance: Clients are able to miss one sessions as life does happen. Missing two or more classes/sessions will be an automatic termination. Clients will start over if they miss sessions. Dates of missed session will be listed on your letters. Client can attend 10 weeks or more depending on the request of the court order. Clients are responsible for fees before session or will not be allowed to enter the class and being on time. Clients have the choice to attend groups or individual sessions. *Please refer to the list of classes on the website. If at any time a client’s becomes disrespectful in any way during session or group he or she will be terminated. This is for the safety of the the group members in person and/or virtually. Punctuality: Clients are to arrive on time to begin sessions either group or individual sessions. Only 5 min late arrival is allowed, if there is a consistent late arrivals you will be terminated. Please note that rare the time facilitator may also run late yet clients will be informed ahead of time if possible. I accept the rules listed above. *

Yes I agree and accept

Progress Letters & Letters of Completion

Letters: Clients can request a progress letter at any time and will be provided with in 24hr- 48 hrs Letter of completion are provided at the end of the last class. Letters will be emailed to the email you have listed in your enrollment form. Copy of letters are $5.00. *

I agree and accept

Behavior

Behavior: Clients are to be respectful towards everyone in the group and facilitator. If facilitator observes negative comments or behaviors he/she may be asked to talk to facilitator to discuss any issues that may be resolved. Abundance Guidance Center has the right to have any client end services at any time for any negative approach, comments, and behaviors. A client is always welcome to talk to facilitators with any questions or concerns he/she may have. Facilitator can terminate a client at anytime if she finds it necessary for the safety of the group. Virtual behavior: All clients must be respectful while others are sharing during class. I understand the behavior rules. *

I agree and accept

Court Ordered Clients

Court Mandated: Clients who are court mandated MUST attend consistently and inform facilitator if he/she will not be able to attend class. DCFS/CPS workers will contact Abundance Guidance Center to follow up on client’s progress. Abundance Guidance Center informs social worker if clients are participating and how the client is participating or not. There are no make up days available as a group. Only private makeup days are available $50 per session if available slots. Probations officers will be provided update on your attendance and cooperation. *

I agree and accept

This consent for services is effective for the duration of my participation during the classes I have enrolled for with Abundance Guidance Center. I agree with the policies above. I have been given the opportunity for discussion of any concerns that I have regarding the series. I am aware that new policies may be added at any time and I will notified if pertains to my situation. I am aware that I am responsible with fees, punctuality, cancelations, reschedules, and to be positive and open minded in learning ways to help myself. Any other rules can be added at anytime without notice, for the safety of the group. *

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Please Choose Carefully

Please make sure to check you are able to attend alone without the other parent if you are currently in a co-parenting custody case. We do not not give any refunds for not reading your minute order. If you have any questions please call or text 562-639-2734.

What classes are you enrolling for? *

Court Ordered Co-Parenting

Volunteer Co-Parenting

How many weeks? * 🛈

10 weeks

Other

If you choose OTHER, what are the number of classes you will be needing if not listed above?

What court were you referred from? *

Department of Child and Family Services

Custody Case

Criminal Court

I am volunteer

Why do you have an open case? What happened? Short explanation. If you are a volunteer please type NONE ABOVE *

Appointment Information

You will be provided with the first available appointment via email. *

Email - Please make sure you typed the correct email address

Email *

It is very important to not miss your first appointment. Parents are only allowed one credit for no show's and for last minute reschdules. To avoid lossing your session fee please DO NOT MISS any of your appointments. If you provide 24 hrs in advance notice you will be given a credit for next weeks session.

Please check your email for link to class. Also please check your spam folder.

Payment

Payment Options: NO REIMBURSEMENTS AFTER PAYMENT HAS BEEN COMPLETED PLEASE MAKE SURE YOU CHOOSE YOUR OPTIONS AND READ YOUR MINUTE ORDER BEFORE ENROLLING.

Enrollment fee for ONE: $60.00

Each group class: $80.00 per session

Fees: Please choose carefully. NO REIMBURSEMENTS AFTER COMPLETING ENROLLMENT. * 🛈

Enrollment only $60.00

Enrollment $60.00 + 1st Class $80.00

Current Total:

$0.00

Please make sure you complete credit card/debit information using PayPal for secure processing. You do not need to have a PayPal account to complete payment.

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

PAYMENTS:

If you choose to pay weekly or monthly, you are responsible in paying before attending class. Please notify your class instructor if you will pay using Venmo, Zelle, or PayPal. Your instructor will send you the direct link for payment.

By signing you agree to follow all agency rules at all times, virtually or in person. The information I provided on this enrollment form is correct. I am aware that any pending fees will have to be paid before class. I am responsible for attending sessions on a weekly basis. I am aware that all classes are conducted virtually and it's my responsibility to be in a non distracting space during sessions. The facilitator is a mandated reporter and any child abuse and/or elder abuse will be reported to the Department of Children and Family Services. *

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