Collaborative Divorce Agreement

Licensed Mental Health Professional

(Coach or Child Specialist)

INFORMED CONSENT

You have agreed to enlist my participation on your Collaborative Team as your

___________. As part of this process, you have been given information about my

background, experience, and qualifications.

This document contains important information about my professional services and

business policies. By signing this agreement you give me permission to provide

__________________ services to you. Please read this information carefully and note

any questions so we can discuss them.

THE ROLE OF COLLABORATIVE

MENTAL HEALTH PROFESSIONAL

1. The Collaborative Divorce Coach

Divorce Coaches are licensed mental health professionals. In individual and joint

meetings (with or without attorneys present) the Coaches work with the parties to:

 Identify and prioritize the concerns of each person

 Make effective use of conflict resolution and communication skills

 Develop effective co-parenting skills

 Work collaboratively with the couple, their attorneys, and other involved

professionals to improve communication, reduce misunderstandings, aid

in resolving disputes

1. Child Specialist

Collaborative Divorce Child Specialist will work with the children and the parents to:

 Provide the child/ren with an opportunity to voice his/her/their concerns

regarding the divorce

 Provide the parents with information and guidance to help their child/ren

through this process

 Give information to the Collaborative team that will help the parties in

developing an effective co-parenting plan for their children

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THE COLLABORATIVE DIVORCE COACHING PROCESS:

Collaborative Divorce Coaching involves a joint effort between client/s and coach.

Progress and success in the Collaborative divorce process can depend upon many factors,

including your motivation, effort, availability for meetings, the level of conflict between

you and your spouse/partner/co-parent, the complexity of your family situation, and

outside circumstances (such as the potential impact of interactions with family, friends

and others).

Collaborative does not mean easy. You are facing important personal decisions during a

time of likely emotional turmoil, and your final agreement will be shaped by both parties

in a way that will be unique to your family’s circumstances. This requires flexibility by

both parties so that a fair and mutually equitable agreement can be achieved.

While a successful outcome cannot be guaranteed, your commitment to the process is

essential for a positive and collaborative outcome.

MY PROFESSIONAL COMMITMENT

During the initial consultation period, you and I will jointly determine if I am an

appropriate Collaborative Coach or Child Specialist to work with you. If not, I will refer

you to other mental health professional. If at any time while we are working together I

determine that you would benefit from collateral work with other professionals outside of

Collaborative team, I will discuss this with you and the team. If needed, I will provide

you with the names of appropriate professionals. Examples of such referrals would

include psychotherapists, physicians, and learning specialists.

As a part of the consultation period, we will discuss how I work in the Collaborative

process. If at any time during the process you have any questions about the services being

provided, please ask for clarification.

EMERGENCY SITUATIONS

Although I check my email often, I may not be available for immediate emergencies or

for after-hour or weekend contact. If you require this kind of professional support, please

let me know and I will refer you to other mental health professionals who offer this

service.

If a situation should arise in which you believe that immediate help is needed and I am

not available, I suggest you call your primary care physician or any hospital emergency

room. You can also call 911.

CLIENT CONFIDENTIALITY AND CLIENT SAFETY

The parties and all professional members of the Collaborative team agree that all notes,

work papers, summaries, written or oral opinions, and written or oral reports (collectively

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referred to as the work product) shall be confidential within the process and shall not be

released to any person or entity outside of the collaborative process. This confidentiality

does not prohibit the furnishing, upon request, of such work product to a collaborative

professional involved, by your agreement, in this process.

Should any party or team member elect to terminate or withdraw from the Collaborative

Divorce Process, all materials, including all content (both written and oral) of all

Collaborative Team meetings and communication with/between any member of the

Collaborative Divorce Team or the parties may not be used in any court proceedings.

While the role of coach/child specialist is different from the role of psychotherapist, I am

in practice as a licensed clinical social worker. The confidentiality of communications

between my clients and me as a Collaborative practitioner is important and is protected

by the laws and ethical standards governing the practice of social work. With the

following exceptions, information given in the Collaborative Process will not be shared

with anyone outside of the Collaborative Team and the parties. Please note that these are

standard HIPAA (federal privacy statute) exceptions to confidentiality, and not specific to

the collaborative process:

Exceptions to client confidentiality:

1.) If a client communicates directly to me a threat of physical harm to an identifiable

person, or damage to an identifiable person’s property, I am required by law to

warn the intended victim and notify the police.

2.) If I believe that a client is in a mental or emotional condition where he/she poses a

danger to him/herself or others, I may breach confidentiality or contact others to

facilitate the client’s safety.

3.) If I have a reasonable suspicion that a client may be unable to care for

him/herself, or may be unable to provide for his/her basic personal needs for

clothing and shelter, I may breach confidentiality to facilitate the client’s safety.

4.) If, in my professional capacity, I have a reasonable suspicion of child abuse or

neglect, or abuse of dependent, disabled or elder adult (age 65 or older), I am

required by law to file a report with the designated protective agencies.

If the use of collection agency becomes necessary, I will furnish them with the require

information to collect the fees due.

OPEN COMMUNICATION

The Divorce Coach/Child Specialist may communicate with the parties and the

collaborative professionals including, but not limited to, communicating with each party

individually or together, a party with his or her collaborative lawyer present, each

collaborative lawyer individually or together, any lawyer consulted for an opinion during

the collaborative law process, and any other professionals retained by the parties who

have signed a participation agreement in this matter.

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The parties hereby authorize and release the Collaborative Divorce Coach/Child

Specialist and the collaborative lawyers to share any information, opinions and/or

communications regarding this matter with any of the participants, specifically with each

other, individually or collectively; with any lawyers consulted for an opinion during the

collaborative law process; with any other professionals who have signed a participation

agreement in this matter; and /or with the parties, together or individually. The parties

understand and agree that the Collaborative Divorce Coach/Child Specialist, at her

discretion, may reveal to one party what has been communicated by the other. However,

if you share information with the Collaborative Divorce Coach which you specifically

wish to keep confidential (i.e., not to share with the other party), please apprise your

Divorce Coach/Child Specialist of that fact so that the issue can be discussed and an

agreeable resolution reached. For example, if said information is not germane to the

Collaborative Divorce Process, it may be eligible to be kept confidential.

In order to more effectively provide service, it may be important for me to communicate

with any previous or concurrently treating professionals. To this end I may ask you to

sign a confidentiality waiver form allowing such communication. By signing this

document you are agreeing to promptly provide me with all necessary and reasonable

information I may request, and to sign all authorizations I may deem necessary toward

that end. You are, of course, free to review such authorizations with your counsel prior

to signing.

MEETINGS WITHOUT COLLABORATIVE LAWYERS

It is contemplated that the Collaborative Divorce Coach/Child Specialist may meet with

the parties without the collaborative lawyers present. The Coach/Child Specialist shall

promptly update the lawyers or other team members on any such meetings. The

Coach/Child Specialist may communicate such preliminary understandings in writing or

orally, but shall not draft any final agreements. The Coach/Child Specialist will be paid

for the time it takes to prepare such correspondences and engage in such

communications. The parties will not be asked to memorialize such understandings. The

parties will not sign any binding agreement without both lawyers’ review.

FEES

My Collaborative Divorce Coaching fee is $ per 60-minute session. My fee for attending

meetings with attorneys present (5-ways, or 6-ways) is $ per hour. My fee for case

management, which includes email review, email preparation, report writing, document

review, phone calls with attorneys, oter therapists, teachers, or with clients themselves is

$ per hour (billed in a minimum of 5 minute increments).

I ask that clients pay a $ retainer As the retainer is depleted, we will will discuss

whether to proceed with another advance payment for services or switch to a “pay as you

go” policy. A 3% surcharge will be added to credit card payments.

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Cancellation Policy: I ask for 48 business hours notice (9am-5pm, M-F) to cancel or

postpone an appointment in order to avoid a full fee charged for that meeting. When an

appointment is scheduled for two parties to meet with me together, and one party cancels

with less than 48 hours notice, that party is the client who is asked to pay the fee for the

missed session.

ELECTION TO TERMINATE

If either party decides that the Collaborative Divorce Process is no longer viable and

elects to terminate the status of the case as a Collaborative Law matter, he/she agrees to,

in writing, immediately inform the other party, their respective coaches, and attorneys.

Please refer to your collaborative participation agreement.

The Collaborative Divorce Team also reserves the right to withdraw from the case if

either or both parties engage in conduct that is contrary to the Collaborative Divorce

Process.

In the event of termination, all incurred fees are immediately due and payable.

In the event of termination, appropriate referrals will be offered to facilitate the client’s

transition out of the Collaborative Divorce Process.

LIMITATIONS

While the Collaborative Divorce Process is not a guarantee of success and cannot

eliminate past disharmony and irreconcilable differences, it offers a positive method

toward a more healthy and cooperative solution to marital dissolution. For couples with

children, it assists them towards a positive and healthy co-parenting relationship.

I HAVE READ THE ABOVE STATEMENT IN ITS ENTIRETY, UNDERSTAND

THE CONTENT, AND AGREE TO ITS TERMS.

______________________________________________________

CLIENTS NAME (PLEASE PRINT)

_______________________________________________________

SIGNATURE Date