Pre-Enrollment Form "*" indicates required fields Name*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone NumberEmail* Name of Other ParentPrimary Phone Number for Other ParentPlease list the names and ages of all children you have with the OTHER PARENT only (To add more than one child, please click the "+" sign to the right of the "age" column)*Child 1 NameChild 1 Age Add RemoveWere you asked (or ordered) by a court to contact us? Yes No Name of JudgeWhich court? (city)When ordered?Next Court DateName of YOUR ATTORNEYName of OTHER PARENT'S ATTORNEYDo you and/or your co-parent have current restraining orders? Yes No Please read the following carefully. When you are done, please click the submit button.I understand that I will be enrolled in one or more co-parenting classes. I understand that co-parenting is not counseling or psychotherapy. I will pay for my enrollment in co-parenting in advance. I understand that the instructor in my class may be a licensed mental health professional. If so, I understand that, as required by California law, a licensed mental health professional must make an official report to appropriate law enforcement agencies if he or she suspects anyone poses a threat to harm oneself or others, has abused a child, or poses a risk to do so. Except for reasons such as this, I am entitled to confidentiality. If, however, the court has ordered the staff of Solutions For Families to communicate to it (the court) about my participation in any phase of co-parenting and/or mediation, I understand that the court order overrides my right to confidentiality.* Click this box to indicate that you have read and agree to the above terms and conditions EmailThis field is for validation purposes and should be left unchanged.
