Cogmed Contract Agreement

  • For a print version click here

    Cogmed Contract Agreement
    Welcome to The Southfield Center for Development. Please take a few moments to thoroughly review this form as it contains important information regarding our office policies and procedures. Please feel free to jot down any questions so that they may be fully discussed. Once you sign this form, it will constitute a binding agreement between us.
    The Southfield Center for Development looks forward to providing Cogmed Working Memory Coaching services for your child.
    Professional Fees:
    Our fee for the Cogmed Working Memory Training Package is $1,450. This includes 8 sessions: an intake/start-up session, 5 coaching sessions, a wrap up session and a follow up session. In addition to the session fee, we reserve the right to bill for any phone calls, email communication, or meetings with school staff or parents that exceed fifteen minutes in duration. This will be based on an hourly session fee of $150.
    Cancellation Policy:
    Cancellations for scheduled Cogmed sessions must be given 24 hours in advance, as this time has been reserved for your child. The hourly session fee or a prorated amount depending on length of individual child’s session will be charged for all missed appointments or cancellations made the day of scheduled session. In the case of sudden illness or other emergency, we can discuss rescheduling missed appointments.
    Contacting Your Child’s Cogmed Coach:
    Our Cogmed staff can be reached at the Center at 203-202-7654 during business hours. Due to our type of work, we are often not immediately available by telephone when we are with clients. When we are unavailable, our telephone is answered by a voice mail that is monitored frequently. We will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available.
    Payment Policy:
    The Southfield Center for Development requires payment in full at the time of service. As such, it is recommended that you keep a credit card on file for ease of payment. To do so, please complete, sign and return the Credit Card Authorization form along with this agreement. If you prefer not to keep your card on file, payment is still required at the time of service. Please note that tutors do not collect fees, and all payments must be made directly through the center.
    If your child is seen at home, or if you are not directly escorting your child to the Center for his or her appointments, we require that you keep a credit card on file. In these instances, your card must be on file in advance of your child’s first session.
    Professional Records:
    Parents please note, pursuant to federal guidelines, The Southfield Center keep protected health information about your child. This professional record includes your child’s clinical evaluations, a description of the ways in which your child’s learning services issues impacts their life, their diagnosis, a treatment plan, progress notes towards those goals, treatment history, any previous evaluations or Individualized Education Plan that have been received from other providers, reports of any professional consultations, and any reports that have been sent to anyone, including reports to your school.
    Permission to Release/Exchange Information Between Southfield Center Practitioners:
    The Southfield Center for Development is a multidisciplinary child development center that provides diagnostic, therapeutic and educational services in a collaborative environment. Our clinical and administrative team is dedicated to helping children and adolescents achieve their full potential. The exchange of information between Southfield Center providers, including but not limited to psychologists, psychiatrists, social workers, marriage and family therapists, speech pathologists, occupational therapists, learning specialists, education advocates, and executive functions coaches (collectively “Providers”), is part of what allows us to provide the highest level of service to the children and families we serve.
    By signing this contract, you authorize information release/exchange concerning your child (or yourself, if you are the client being seen, and are 18 years of age or older), among Southfield Center providers. You understand that this information may be used for the provision of services, exchange of treatment information, diagnosis, progress and historical data, and continuation of the provision of services. You also understand that it is your right to revoke consent at anytime, except to the extent information has been released, obtained, or exchanged as originally permitted.
  • This field is for validation purposes and should be left unchanged.