Amy Mozolik, PsyD

Clinical Psychologist Phone: 907.306.6760

PO Box 230812 Email:

401 E. Fireweed Ln, Ste 201 Fax: 844.513.4092

Anchorage, Alaska 99523

Child Therapist Agreement with Parents

Due to the nature of the therapeutic process and the fact that involving legal counsel often involves making a full disclosureof any and all information the therapist holds with regard to many matters which may be of a confidential nature, it is required that you agree to the following: that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client), nor your attorney, nor anyone acting on your behalf will call on me to testify in court or at any other proceeding, nor request a copy of the psychotherapy records. This action can be particularly harmful to children who believe they are sharing information in a safe place that is then revealed in court. Court testimony can and often does damage a child’s trust in their therapist and usually ensures that at least one parent - generally the one that the child expresses the most anger, discomfort, or difficulty with - will believe that I am not doing a good job with the child. A therapist and a child custody evaluator are not the same thing and should not be treated as such.

  1. My role as therapist for your child is to create a therapeutic and safe environment for the sharing of feelings including those related to divorce. It is understood that my neutrality in any parent or parenting disputes is for the benefit of your child.
  2. If your child is an adolescent, it is possible that he/she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of normal adolescent experimentation, but at other times they may require parental intervention. We must carefully and directly discuss your feelings and opinions regarding acceptable behavior. If I ever believe that your child is at serious risk of harming him/herself or another, I will inform you.
  3. One risk of child therapy involves disagreement among parents and/or disagreement between parents and therapist regarding the best interests of the child. If such disagreements occur, I will strive to listen carefully so that I can understand your perspectives and fully explain my perspective. We can resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress.
  4. As your child’s therapist, I will not address conflictual issues between parents. Any concerns regarding visitation or parenting can be addressed by hiring a child custody investigator or a collaborative divorce attorney (please see Alaska Association of Collaborative Professionals).
  5. It is also understood that once therapy has commenced, I will not speak with either of your attorneys, nor will I appear in court proceedings related to divorce, parenting or visitation disputes. Should you or your attorney disregard this agreement and compel a judge to call on me, I will charge you but I will still NOT provide parenting or custody recommendations. Additionally, if I am called to court or if you request your child’s records for litigious purposes, this may cause irreparable damage to the therapeutic relationship I have with your child, and it may be necessary for me to terminate our therapy.
  6. In support of your child’s therapy, each of you, by signing this agreement, acknowledges your willingness to cooperate by providing transportation to and from therapy at the agreed upon dates and times.
  7. It is understood and agreed upon that should you violate this agreement, I have the right to terminate therapy with your child. If either parent decides that therapy should end, I will honor that decision. I do, however, request the option of one or two closure sessions with your child so that therapy can be ended in a good way for the benefit of your child.
  8. Payment will be the responsibility of one parent. You will inform me of which parent will be financially responsible.
  9. The therapist will meet with parents together or separately, depending on your preference; phone calls will be made to parents individually at the parent’s request, and emails may go to/from the therapist and both parents together or individually to parents. While you may request your preference for these methods of interactions, they will ultimately be at the therapist’s discretion.

The parent who will be responsible for financial obligations and payment of services to the therapist is: ______

By signing this agreement, you will be waiving your right of access to your child’s treatment records.

If, despite this agreement, I am required by a judge to appear in court on your behalf, or

on behalf of your child, please note that I charge a $700.00 flat fee and $300.00 per hour for court appearances/testimony, with a $1000.00 minimum. This fee will be assessed if I am scheduled for court on your behalf, and is not contingent upon my actual participation or testimony. The fee will be the responsibility of the parent who requested my appearance, or whose attorney requests my appearance.

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Signature of custodial parentDate

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Rev. 11/15