At Devine Counseling Services, LLC, we require consent to services by both parents, despite the law in NJ only requiring one parent’s consent for services to assure that both parents are informed and have access to their child’s care. Within this practice, it is the policy/protocol for both parents to (i) give consent to treatment and (ii) have a parent consultation prior to the start of treatment to discuss the following.

• This office requires consent for services from both parents.

• This office requires a court order and/or separation paperwork to understandphysical/legal custody to the extent that such documentation may exist.

• Prior to services being rendered, we need to discuss treatment goals, clearboundaries, and how we will communicate with both parents.

• This office will NOT provide letters or documentation related to treatment for courthearings.

• This office will NOT make any recommendations related to custody.

• This office will NOT allow treatment records to be read or reviewed by any courtor any attorney or expert for any party to any court proceedings, or any thirdparty.

• This office will NOT conduct facilitation of therapeutic supervised visitation orparent fitness, as that is outside of our scope of practice and needs to be referred out to a reunification therapist.

"We, the parents/legal guardians of our child (named below) have decided to bring our child to Devine Counseling Services, LLC for therapeutic treatment."

• We understand that our child is the client. This is true no matter who pays for the evaluation/treatment of my child.

• We understand that it is our responsibility to provide information regarding custody arrangements, contact information of the other parent, and copies of all court orders; and failure to do so may cause Devine Counseling Services, LLC to cease providing services.

• We understand that if payment is not received promptly for services rendered to my child, the services may be suspended or terminated, pursuant to the ethical guidelines governing mental health care.

• We understand that any Devine Counseling Services, LLC therapist will not appear as an expert witness or to testify on our behalf or on the behalf of any other individual at any deposition, court proceeding, or any type or stage of litigation.

• Devine Counseling Services, LLC, therapist will not allow treatment records to be read or reviewed by any court or any attorneys or experts for any party to any court proceedings or any other third party without a HIPPA compliant court order.

• We understand that Devine Counseling Services, LLC will not provide any testimony, letters, reports, or evaluations of any kind from Devine Counseling Services, LLCor any Devine Counseling Services, LLC therapist to be used in any stage of litigation or any court proceedings.

• We understand that Devine Counseling Services, LLC will not conduct facilitation of therapeutic supervised visitation or parent fitness, as that is outside of our scope of practice. Facilitation of a therapeutic supervised visitation or parental fitness will be referred out to a reunification therapist.

• We understand that nothing written above limits your rights to request your child treatment records from Devine Counseling Services, LLC as your child’s healthcare representative.

Legal Guardian 1

I have read the above paragraphs and understand them. By signing below, I agree to the above.

Legal Guardian 2

I have read the above paragraphs and understand them. By signing below, I agree to the above.