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SCPC CUSTODY CONTRACT
S.C.P.C. POLICIES REGARDING JOINT CUSTODY

  1. SCPC providers do not conduct custody evaluations or give custody opinions.
  2. If parents have joint legal and medical custody, both must agree on the treatment plan for the child/children to be treated by SoCal Psychiatric Care.
  3. In court custody matters, children’s records will be released only by an order by the judge or to an attorney appointed by the court to represent the child. In court matters, children own privilege to their records.
  4. . Records will not be given to the parents. Such violation of confidentiality would destroy the therapeutic relationship.
  5. All parents, even non-custodial parents have the right to know how the child is doing in therapy.
  6. If adversarial conditions between the divorced parents are contaminating the child’s therapy and causing the child additional guilt, anxiety, and stress, the SCPC provider will recommend termination of therapy until the parents attend Parent’s Turn, and/or the children attend Kid’s Turn, a community service to aid the children of divorce.
**Both parents must initial Parent Initials (
)/ (
) Parent Initials (
)/ (
)
Patient Name
Patient Email
Patient Phone

COMPLETED BY BOTH PARENTS OF CHILD
Childs Name:
DOB

I give my consent for my child to be treated:

(both parents initial)
  1. Transportation will be arranged by the parent who the child is residing with on the day of the schedules appointment and/or agreed upon mutually between parents.
  2. The parent scheduling the appointment will be responsible for canceling appointments within 24 hours and/or paying any associated late cancellation fees. Parents agree to communicate with each other when cancelling or rescheduling appointments.
  3. Copays/Deductibles are to be paid at the time of session, please list only one (1) parent who will be financially responsible for all balances even if both parents are legally responsible for payment.
  4. So Cal Psychiatric Care does NOT do mediation or get involved with parents financial arrangements.
Name of Financially Responsible Parent:
Address of Financially Responsible Parent:
By signing below, I have read and agree to the policies above A through D.
Parent Signature:
Phone Number:
Parent Name (printed):
Date
Patient/Legal Representative Signature
Phone Number:
Parent Name (printed):
Date
      Please click here to download a blank form.

*Note: This custody contract AND pages 1 & 2 of “So Cal Psychiatric Care’s Welcome Packet” (found on our website) needs to be signed separately by both parents. Please ensure this contract and /or all paperwork is completed and signed by both parents prior to child’s appointment to avoid the child’s appointment being rescheduled or cancelled. These policies are consistent with California State Laws.