Whole Family Intervention Consent Agreement

Treatment in Therapy Consent Agreement(Required)
You are required to read through the following terms and conditions. When you have reach the end, checking the box will satisfy the agreement to be submitted.



A. Role of the Family Intervention Coach(es):

The family intervention coach(es) assists the entire family in understanding how each family member contributes to the family dynamic. One or more coaches may be involved with the family depending on the family’s needs and complexity of the family’s situation.

The coach(es) provides a structured setting for a productive exchange of information with the goal of helping the family create a playbook for moving forward.

The coach(es) determines the format of the meetings and the meeting participants (one parent, both parents, parent and child(ren), both parents and child(ren), child(ren) only).

The coach(es) collaborates and provides interventions during the process, including support for:

  • Quality, age-appropriate parenting
  • Cooperative or parallel co-parenting
  • Individual parent growth

The coach(es) may cite research and otherwise educate the parties on matters related to their family dynamic, such as child development, best practices of positive parenting, and strategies for successful co-parenting or parallel parenting.

The coach(es) treats all content of the intervention as confidential within the limits of a court order, if applicable. A release of information is required to share information with any other party. This signed consent agreement authorizes the family intervention team to collaborate and consult on the whole family intervention process without the need of any other signed release of information.

The coach(es) works with other professionals involved in the family such as attorneys, guardian ad litem, parenting coordinator, or therapists. The coach(es) will inform the parties if the coach(es) requires a release of information to speak to another professional.

The coach(es) does not serve as an expert or witness in any court proceeding.

The coach(es) does not give legal advice. If this agreement is to be made into a court order, the parties must seek legal counsel to complete the proper paperwork and follow required procedures.

The coach(es) is not serving in the role of a therapist or social worker. If the family intervention coach determines that psychotherapeutic interventions would be helpful for the a member of the family, the coach(es) will make a referral to an appropriate therapist.

The coach(es) holds no liability for any outcomes or consequences resulting from the family intervention process or terms of any legal agreement.

B. Role of the Parties:

Family members meet with the coach(es) in various combinations; child(ren) only, child(ren) and either parent, child(ren) and both parents, only the parents, or only one parent.

The parties will answer the family intervention coach(es) questions as completely and honestly as possible. They will also engage in the family intervention process to the fullest extent possible with a focus on creating shared messages for the parents to deliver, jointly and separately to the child(ren).

The parties will make a good-faith effort to be open to ideas that may promote a path forward and a productive co-parenting plan in the best interest of all parties.

The parties will work individually with the coach(es) so they are able to demonstrate responsibility, managed emotions, an open mind, flexible thinking, and positivity for a new future.

The parties work to create or restore a family dynamic where the parents make the decisions supported by both parents. The parties work to understand the impact of their behavior on the child(ren) and the overall family dynamic.

The parties will provide a release of information to speak to other professionals as required by the coach(es).


A. Appointments: Appointments with the family intervention coach(es) shall be scheduled at the request of the coach(es) or the parties. Intervention sessions may take place with any combination of family members. Standard family intervention appointments are 1-2 hours in length. Additional conversations may take place by telephone.

B. Confidentiality: All communication between the family intervention coach(es) and parties is confidential within the limits of a court order, if applicable. Any sharing of information between the coach(es) and any other party requires an authorization form signed by the parties giving written permission for a release of information. Either party may request a conversation or meeting with the coach(es) without the knowledge or consent of the other party. All communications between the coach(es) and the parties will be private and confidential unless a release of information has been signed and submitted to the coach(es) for the purposes of communicating with other parties. Audio/Video recording is strictly prohibited and is grounds for immediate termination of services.

C. Communication: The parties may contact the coach(es) by telephone or email. The coach(es) will make every effort to respond within 2 business days. If email or other electronic messaging is used for sharing or receiving any information, confidentiality may be compromised due to limits to what can be kept private over the internet or phone service.

D. Cancelled or missed appointments: The parties shall pay in full one-hour of service for any cancelled or missed appointments unless 24-hour cancellation notice is given.

E. Termination: The parties(s) may terminate services at any time. The coach(es) may terminate services at any time including but not limited to the following reasons; lack of progress, inappropriate behavior, lack of payment for services or unauthorized audio/video recording of a session.


Parties shall pay for appointments at the time of service. Fees are as follows:

  • Assessment fee including summary report - $3250
  • Individual or joint sessions with a single coach - $250.00/hour
  • Joint session (more than one person) with multiple coaches - $250.00/hour per coach
  • Fees for additional time spent drafting documents, telephone or email conversations are billable at $250.00 per hour, calculated at 10-minute intervals.
  • The coach(es) may require a retainer for the purposes of phone and email communications. The coach(es) will notify the parties before any charges are accumulated for telephone conversations or email exchanges.
  • Family intervention services are not covered by insurance.


Parties understand that the family intervention coach(es) is obligated under law to disclose the following information to appropriate authorities: 1) allegations of abuse or neglect of a child, 2) threats of harm to self or others, 3) statements made indicating plans to carry out or hide an ongoing crime, and 4) statements made that reveal a felony crime.

MM slash DD slash YYYY

951 High Street Suite B Worthington, Ohio 43085
614.578.5190 www.thecenterforfamilyresolution.com