Breakthrough Parenting: Co-Parenting High Conflict Focused Enrollment ATTENDING TOGETHER Consent for Services Form

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

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. *

Information of Children

Please provide your childrens first and last name.

Child 1 Name & Last Name *

Date of Birth * +

Child 2 Name & Last Name

Date of Birth +

Child 3 Name & Last Name

Date of Birth +

Child 4 Name & Last Name

Date of Birth +

Additional children please list all of their first names and last names.

Information of other parent

First Name of the other parent

Last Name of the other parent

Gender

Female

Male

Minors Counsel

Do you have a minors counsel assigned to your case? (a minors counsel is an attorney assigned to your child by the judge) *

Yes

First and Last Name of Minors Counsel

Telephone number of minors counsel

Email of minors counsel

Emergency Contact

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 *

Facilitator Role: Please read

Co-Parenting:

Parents enrolled for Co-Parenting High Conflict Focused are responsible in notifying each other and facilitator of any cancelations, reschedules, questions, and concerns. If one parent shows and the other fails to notify their cancelation, the parent who shows will be provided a letter stating the other failed to inform.

Any parent that demonstrates any type of negative behavior towards facilitator and other parent will be informed to end services. Yet, if both or one parent demonstrates no interest in the co-parenting session a letter explaining the reasons will be provided explaining the reasons why parents will no longer be attending. If one parent demonstrates consistency in communication and showing up to sessions as requested and the other parent does not show any interest, the non succesfull letter will show the lack of cooperation of the other parent and the effort of the other.

If a parent does not agree with center policies he/she will have the choice to end services or resume with written statement why they will continue the classes.

Facilitator can terminate sessions at anytime if she feels it necssary. If one parent demsontrates no trust amd/or communicates to outside parties his/her concerns/complaints sessions will be terminated for liability resons. Parents will recieve a termination letter and any payments made in advance will be refunded.

If parents do not successfully complete the co parenting program facilitator will add on the final letter her observation on both parent’s behavior and/or cooperation

Co-Parenting Facilitator Role:

A Co- Parent facilitator (CPF) is a person who is appointed by the court to assist parents in split families in resolving parenting issues using procedures that are not confidential (no secret policy between parents and facilitator). Even so, the court may appoint a CPC and put in place some measures to protect the parent and child's safety.

The Co Parenting Class Will Cover:
• Emotional effects of divorce.
• Emotional and behavioral reactions to divorce by children.
• Parenting issues relating to specific developmental stages.
• Stress indicators in children.
• Conflict Management.
• Family stabilization through Parenting relationship development.

Every case is different and since parents normally do not have a healthy co-parenting, Faciliator will remind clients of any possible child abuse reports that will be made or can be made depending on the information shared in session. Parents must keep confidentiality at all times. Please avoid sharing what happens in session to third parties. Facilitator will address any concerns to parents when needed.

Facilitator will add on the final letter any recommendations to the court based on her observation of the sessions with parents.

Parents are not allowed to:

Record the sessions

Threat the other parent

Disrespect each others family members

Curse at each other

Manipulate their child to the benefit of a parent

Facilitator does not choose sides and will be very clear with her concerns to avoid any misinterpertation. Facilitator does not attend court to represent neither parent.

Additional rules will be added without notice to help resolve any issues that may occurr.

I have read the co-parenting rules and facilitators role. *

I agree and accept the co-parenting rules listed above.

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. 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. *

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

What classes are you enrolling for? *

Co-Parenting High Conflict Focused

How many weeks? (if you were not informed how many classes to take, please check 10 weeks as it is the minimum classes you can take. * 🛈

10 weeks

12 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 *

Schedule Options

Co-Parenting High Conflict Sessions are scheduled in the evenings during the week. You will be notified by your facilitator of your scheduled date and time. Parents are provided with the first available time and date. * 🛈

I am available to meet in the evenings

Virtual link and appointment date and time will be sent via email *

Email - Please make sure you typed the correct email address

Your email *

IMPORTANT: Parents are only given one credit. If you miss your first appointment you will get credited for the following week. If you miss the second appointment and its a no show or last minute cancelation you will automaticaly lose your $80 payment. All payments MUST be made one day before. If parents do not make the payment the day before you will not be seen. If the other parent did make their payment and they show for session, that parent will be provided with an email with proof of their attendance and no show for the other parent due to not making the payment and/or not showing for session.

Payment

Payment Options: NO REIMBURSEMENTS AFTER PAYMENT HAS BEEN COMPLETED PLEASE MAKE SURE YOU CHOOSE YOUR OPTIONS AND READ YOUR MINUTE ORDER BEFORE ENROLLING. If you are not sure if the other parent will be enrolling you have three options: 1) Enroll and get your proof of enrollment for your records or 2) Wait for the other parent to enroll and then register but it is your responsibility to follow up by contacting the center. We only contact both parents when both parents enroll. 3) Start co-parenting classes on your own only if the judge or attorney approves . (If you are choosing to attend alone you must exit this enrollment and go back to the home page on the website to enroll under "Co Parenting Attending Alone")

Each parent will pay their fee sepreatly

Enrollment fee for ONE: $60.00 per parent

Each group class: $80.00 per parent

If you choose to pay only for Enrollment and pay weekly. Please make payment using Zelle using 562-639-2734 under Amapola Ramirez.

Fees: Please choose carefully. NO REIMBURSEMENTS AFTER COMPLETING ENROLLMENT. You can only receive the discount when paying the full amount before attending the first session. * 🛈

Enrollment + 1st Session

Enrollment Only $60

12 weeks co-parenting + ENROLLMENT

10 wks co parenting + ENROLLMENT

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. You can pay as guest.

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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