Separated Families – Intake Agreement & Policy

Parent 1 - First Name *

Parent 1 - Last Name *

Parent 1 - Email address *

Parent 1 - Phone Number *

Parent 2 - First Name *

Parent 2 - Last Name *

Parent 2 - Email address

Parent 2 - Phone number

Please note that we need a separated agreement completed for each child

Child - First Name *

Child - Last Name *

1. Purpose of this Agreement

This agreement outlines the conditions under which psychological services are offered to children and adolescents by Roxanne David Psychology Pty Ltd T/as Happy Brain referred to in this agreement as "Happy Brain" where separated parenting arrangements exist. The focus is to ensure services are delivered in a manner that is safe, ethical, child-centred , and aligned with the Australian Psychological Society (APS) Guidelines for Working with Separated Parents (2017) .

2. Consent and Parental Responsibility

Informed Consent is required from all individuals with legal parental responsibility , unless a court order states otherwise.
Parents must provide copies of current Family Court Orders , Parenting Plans, or any Interim Orders to Happy Brain prior to commencement of services.

Happy Brain Policy:
We require copies of all relevant court orders and parenting agreements to be provided and kept on file before therapy begins. Services will not proceed without this documentation.

Please indicate: *

I have sole parental responsibility and attach a relevant court order.We share equal parental responsibility and both parents will sign this agreement.There are current legal proceedings – details provided separately.

Details of the legal proceedings in place:

3. Court Proceedings and Impact on Service Provision

Ongoing Family Court proceedings may limit or pause service delivery if therapy risks being used to support legal arguments or where parental conflict escalates.
Happy Brain Psychology clinicians do not provide opinions on parental fitness or custody recommendations.
If a court requests a report or subpoena is issued, we have a legal right to comply with the Court with this agreement providing written consent to provide this information to the court and agreement to associated fees.

4. No-Contact Orders and Safety

If a no-contact order (e.g., interim order, Domestic Violence Order or any other order of the court in any state in Australia) is in place between parents, this must be disclosed immediately, and a copy will be supplied to Happy Brain for our records.
Where risk is present, Happy Brain will implement safety measures, including separate parent appointments, telehealth, or declining joint participation.
Clinicians at Happy Brain will follow conditions outlined in court orders and prioritise the child’s physical and emotional safety at all times.

5. Confidentiality and Parent Access to Information

Session content with children and adolescents is confidential. Parents may receive general updates on progress , but not detailed disclosures unless risk is involved or if consent is obtained from the child.
Information will be shared with both parents only if they share parental responsibility and unless doing so may place the child at risk or is inconsistent with court orders.
Communication with schools, doctors, or other third parties will occur only with signed consent.

6. Gillick Competent Adolescents

In accordance with the Gillick principle , adolescents who demonstrate sufficient maturity and understanding may independently consent to treatment and make decisions regarding confidentiality and information sharing.
Clinicians will assess and discuss this directly with the young person, in consultation with parents when appropriate.

7. Parent-Only Feedback Sessions

Clinicians at Happy Brain may offer parent-only feedback sessions to discuss the child’s progress, treatment planning, or parenting support, with the consent of the child if the Gillick principle applies.
These sessions may occur with one or both parents, depending on court orders and the clinician's clinical judgement.
Notes from these sessions are part of the clinical record and are not designed for legal use. Sessions must remain child-focused and cannot be used to criticise the other parent or support litigation.

8. Financial Responsibility

Medicare Rebates (if eligible) will be processed to the nominated parent or bank account.
Cancellation Policy: A minimum of 48 hours' notice is required to avoid full session fees.

Billing Agreement (tick one): *

Parent/Guardian 1 is responsible for fees.Parent/Guardian 2 is responsible for fees.Fees are shared (please specify arrangement):

Please specify billing arrangement *

Important:

Happy Braindoes not mediate or manage disputes between parents about who pays for services. The parent or carer bringing the child to the appointment (or listed as responsible) is expected to settle the account. If disputes about payment arise, services may be paused until an agreement is reached or prepayment is made. Any request for notes will incur an administrative fee that will be quoted for you when requested.
If both parents have parental responsibility (i.e. no consent orders are in place or when provided so with consent orders) a copy of the notes can be provided to either parent as long as our fees are covered to provide the same. However, if the Gillick principle, the child will have to provide consent to release the notes to the parents, unless consent orders override this principle.

9. Limits of Service

Happy Brain does not:

Make recommendations about custody or contact.
Provide court reports unless agreed in advance and appropriate consent is obtained. Participate in proceedings without a formal subpoena and fee agreement.
No communication will be undertaken with the Indepent Childrens Lawyer unless there is a court order requiring this to occur; then both parties agree by signing this agreement that they will cover the costs of our fees in doing so.

10. Agreement and Acknowledgement

By signing this agreement, you confirm that:

You have read and understood the information above. *

You consent to psychological services being provided to your child by Happy Brain. *

You will keep Happy Brain updated on any legal or custody changes. *

You understand that the child's wellbeing is the central focus of service provision by Happy Brain. *

You agree to all conditions mentioned above.

*

You have not been pressured nor coerced into signing this document.

*

You understand that you have the right to obtain independent legal advice prior to signing this document. *

You agree that both parents have to provide a signed Separated Familities - Intake Agreement and Policy to Happy Brain unless court orders state otherwise *

First name of parent completing this agreement *

Second name of parent completing this agreement *

Signature of Parent Completing this form *

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First name of witness *

Second name of witness *

Signature of witness *

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