Waiver of Confidentiality and Limits of Confidentiality in Court Ordered & Stipulated Cases for Mitchell Rosen, LMFT There is no privileged communication for any party in Court Ordered counseling, investigations, parenting plan coordinator, co-parenting, reunification therapy or custody evaluations. Exceptions are when order states confidential or 3190 counseling. All information obtained during our sessions may be reported to the Judge, mediators, therapists, attorneys, custody evaluators, other agents of the Court and persons designated by Mr. Rosen. I am agreeing to waive therapist/client confidentiality for my minor child and myself. I am authorizing Mitchell Rosen to exchange information with treating physicians/clinicians. I agree Mitchell Rosen shall not be called as a percipient witness. I agree to allow individuals designated by Mr. Rosen to assist at his descretion. I also agree to permit Mr. Rosen to take photographs of my home, my family and myself if a child custody evaluation has been ordered. These photographs may not be published or posted but may appear in a report to the court. This waiver shall reamin in effect until court case is terminated. Behavior in Therapy Office: There shall be no yelling, profanity, sarcasm, rolling of the eyes, or name calling permitted. If you disagree with what is being said by Mr. Rosen or any other person in the room, you may state your disagreement in a clear and polite manner. If Mr. Rosen believes your behavior is inappropriate, he may ask you to be quiet or leave the office. If you are asked to leave the therapy room, you will be financially responsible for not just your portion of the session but the other party’s fee as well. No recording devices are permitted in Mr. Rosen's office without the written permission of all participants. If a child brings a recording device, the parent transporting the child assumes responsibility. Individuals who violate this law are subject to criminal prosecution Under California Penal Code Section 632. Agreement for Child Custody Clients: The fees for a 730, 3111 or 3118 custody evaluations are explained in Mr. Rosen's website: mrosenmft.com in the section: Rates and Insurance. These are flat fees for 2 adults and 2 children and includes all testing, home visits and the final report. There is an additional fee for each additional adult and/or child. If home visits are determined by Mr. Rosen to be essential and your home is greater than one hour from Mr. Rosen's Corona or Temecula office there is an additional fee. Once psychological testing or interviewing has begun, there will be no refunds as significant time has been invested. Financial Agreement for Family Law Clients: I understand I am responsible to pay for services in accordance with the Judge’s Order regarding responsibility of payment. I am also responsible for paying for any report requested by the Court, my attorney or myself (if self-represented). For co-parenting and reunification counseling, future sessions will be set and scheduled at the first appointment. Unless changes to scheduled sessions are made by mutual agreement or in the event of medical/extenuating circumstance, the person changing the scheduled date(s) will be financially responsible for the time incurred by Mr. Rosen's office. Payment shall be by cash, credit card or money order. If Mr. Rosen elects to accept a check and it is not negotiable for any reason a fee of $45.00 will be levied and after 30 days, the check may be submitted for criminal prosecution. I agree to give a minimum of 48 hours notice for any cancellations. Failure to do so will result in being financially responsible for the fees of both parties. Telephone consultations: are available and are charged at the rate of $5 per minute with a minimum charge of $25.00. There is no fee for telephone consultations for child custody clients. Fees and Payments: All payments (excluding child custody) will be made in cash, credit card (may be submitted on Mr. Rosen's website) or cashier’s check. For child custody deposits, personal checks are accepted. Court Testimony: If the Court, my attorney or myself requests Mr. Rosen to testify or provide a deposition, there is a charge of $3,000.00 (three thousan dollars) for the am or pm session or $5,000.00 (five thousand dollars) for the entire day. The fee must be delivered to Mr. Rosen 10 (ten) business days before the testimony/deposition and must be in cashier’s check, credit card or cash (a check from an attorney’s office is acceptable.) The fee is charged if Mr. Rosen testifies for 1 minute, 7 hours or not at all. It is required that 72 hours notice is given if the testimony is not required or the entire deposit is forfeited. My electronic signature is authorization I have read the materials provided in this disclosure, agree with all conditions that are stated or implied and my compliance to them.