Attachment - Child-in-Family Services

Fees for all supervisory appointments with Beth Powell Sanchez, LCSW, are $80 per 60-minute hour for one or more supervisees. This cost also includes completion of paperwork for the supervisee. There is no charge for an initial appointment of 45 minutes to 1 hour to discuss potential supervision. All potential supervisees must familiarize themselves with the Child-in-Family Services’ website to get a full understanding of the services offered at Child-in-Family Services before calling to make an appointment to discuss potential supervision.

Potential supervisees nor supervisees are reminded of their appointments. Missed appointments (no-shows) are billed in full to the supervisee at $80 per hour. Supervisory appointments are pre-paid. A missed appointment (no-show) for the potential supervisee’s initial meeting is not rescheduled. Late cancellations or postponements (changed before appointment time but outside of cancellation grace period below) are billed to the supervisee at ½ of the amount of the scheduled appointment time. Child-in-Family Services charges the potential supervisee $40 to reschedule a late cancelled initial appointment. This office is unable to make exceptions for no-shows, late cancellations or late postponements. But collected fees are donated to a ministry or organization that helps children. The supervisee or potential supervisee agrees to give Child-in-Family Services the following notice of cancellation or postponement by phone, not e-mail:

The below are business days, not Saturdays or Sundays.

-- One-hour appointment: 1 day notice

-- Two-hour appointment: 2 days notice

A $30 dollar fee will be charged for returned checks. Time charged for the appointment begins at the time the appointment was scheduled. E-mail cancellations, scheduling, or rescheduling of appointments are not accepted. One must use the telephone to schedule, reschedule or cancel appointments. The office is closed on weekends and holidays.

General Information:

Please do not come to your appointment more than 10 or 15 minutes early.

What is said in this office will remain private and confidential within the guidelines of HIPAA and The Texas State Board of Social Worker Examiners. The people who work here are under an oath of confidentiality. It is a requirement for this office to keep CEU records. There are exemptions to the confidentiality rule. In situations involving child abuse, there is a legal and ethical responsibility to report the abuse to Children’s Protective Services (CPS). If it is determined that someone is a danger to him or herself or others, then an action to protect must happen. If an agency is paying for your supervision, then it has access to your records.

Supervisee or Potential Supervisee Personal Information: (required fields are marked with " * " )

1. Your Name:

2. Supervisees must receive one hour of supervision for each 30-40 hours of work or volunteer service. How many hours of work or volunteer service for which you are seeking supervision are you completing each month?

3. Place of Work (or Volunteer Service):

4. Location of Work (or Volunteer Service):

5. Your Work Title (or Volunteer Title):

6. Your Phone Numbers: (please supply at least one)
Cell:
Home:
Work:

7. E-Mail Address: *

8. Physical Home Address:

9. Mailing Address (if Different from Home Address).

10. Why are you interested in potential supervision at Child-in-Family Services?

I have read, understood and agreed to the above information and have taken a copy for my records. Any information that was unclear has been explained. The initial appointment has been scheduled for , from to for an estimated number of hours.

Today's Date: In the event I need to cancel or postpone our appointment, I agree to do so by telephone by: (1 to 2 business days before the appointment depending on your appointment length).

When you submit this form, a copy of this information will be e-mailed to you for your records, using the e-mail address supplied above.