LOS ANGELES SUPERIOR COURT PARENT EDUCATION REFERRAL LIST FOR HIGH CONFLICT PARENTS Application PLEASE COMPLETE

ALL SECTIONS AND ATTACH YOUR RESUME.

(Please note that any information provided on this form may be released to the public.)
Name: Business Address: Business Telephone: E-mail Address:

LICENSE AND EXPERIENCE

Name of Program Supervisor List degree (Masters Degree or Ph.D.), Clinical License Number and Year Obtained: (Attach a copy of license.)

Program Supervisor Years of experience working with families in the mental health field: Provide names, education and experience of the Program Facilitators:

CURRICULUM
(Please attach a copy of your curriculum) Length of Program: (Must be a minimum of 10 hours over no less than 3 sessions, in addition to the introductory or orientation
session.)

Class Size: (Must be a maximum of 16 individuals per group.)

Yes No Does your program require both parents to attend together? Yes No Can parents attend together or separately? Yes No Can parents attend individually only? Will the program be conducted in a language other than English? If yes, indicate language:

FEES
Fee per parent per session? (Please include sliding scale, if applicable.)

PROCEDURES (Please attach a copy of the protocols and report listed below)
Security Protocol: Please attach the security protocol and plan indicating what you do in the event of an emergency (e.g., a client who threatens the safety of others). Domestic Violence Protocol: Please attach the Domestic Violence screening protocol. (Please include if parents with a history of domestic violence are allowed to participate in the program.) Report to court regarding participation: Please attach a copy of your court report form. Complaint Procedure: Please attach a copy of your internal complaint procedures.

I declare under penalty of perjury under the laws of the State of California that the aforementioned is true and correct. Signature: _____________________________________________________
Revised 01/2012

Date:

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PARENT EDUCATION REFERRAL LIST FOR HIGH CONFLICT PARENTS

Declaration
I declare under penalty of perjury the following: Program Supervisor: Education: I have a Masters Degree, Ph.D or Psy.D. My resume is attached. License: I have a clinical license (LMFT, LCSW, or Psychologist). I have attached a copy of my clinical license. Experience: I have at least 3 years of experience working with families in the mental health field. Program Facilitators: (Please note: Facilitators used in this program must meet the following criteria.) Education: The facilitators have a BA or above and are supervised by the program supervisor. Training: I have supervised and co-facilitated at least two series of co-parenting education classes focused on conflict resolution. Curriculum: My program includes the topics listed below:
- Effects of conflict on children. - Characteristics of a business relationship. - Child development and childrens needs at each developmental stage in relation to parents divorce and separation. - Communication skills training. - Co-operative parenting and parallel parenting. - Conflict resolution skills. - Positive parenting.

Attached is a description of the program and a copy of the curriculum. I will notify the list administrator within two weeks of my clinical license being revoked or suspended. I am covered by malpractice insurance. A copy of my malpractice insurance is attached. I understand the Court has the discretion to remove any individual or program from the list should information be brought to the Courts attention indicating that an individual or agency should be removed from the list. Complaints concerning any individual or agency on the referral list will be submitted in writing to the List Administrator. I will not use my inclusion on this list in any advertising.

Program Supervisor Signature

Date

Please submit your completed Application and Declaration Form, along with the required documentation to: Parent Education Referral List Administrator Stanley Mosk Courthouse 111 N. Hill Street, Room 241 Los Angeles, CA 90012 PLEASE NOTE: INCOMPLETE APPLICATIONS WILL BE RETURNED.
Revised 01/2012