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New Client Intake Forms

   Dear {first_name}: The following information will help us develop a rich relationship. Please fill out the personal information to the degree that you feel comfortable sharing the details. Please do so prior to your first session. Your information will be held in confidence. Thank you!

Service Agreement

AUTHORIZATION OF RELEASE FOR SCHOOL RECORDS





I hereby authorize the release of records, documents, or other information concerning
to Ivy’s Dream LLC, the named individual’s advocate and/or his/her representative.

This release covers all school records, including but not limited to: records pertaining to discipline, expulsions, suspensions, attendance, grades, transcripts, testing results and special education.

Ivy’s Dream LLC has permission to speak on my behalf and attend any upcoming meetings pertaining to said student.

I understand that Ivy’s Dream LLC and his/her staff will regard as confidential and privileged any information thus released to them and will use said information for the sole purpose of assisting me with the matters upon which I have sought their advice and assistance.

A copy of this Authorization shall be as valid as the original. This authorization is effective immediately and expires one year from the date signed below.
Yes
Yes
No
No

Release Authorization

Service Agreement






Service:

Ivy's Dream LLC provides educational advocacy, educational development, coaching and mentorship services.



Payment:

Payments are to be made in full and prior to the start of any sessions or program.



Client Cooperation:

This Agreement contemplates full client cooperation in the course of services agreed upon. This
cooperation includes clients agreement to remain active in the recommended programs subscribed by your advocate or liaison. The client recognizes that compliance with recommended services and service
schedule is important and the client agrees to follow the plans implemented and carried out and agreed upon. The client understands that lack of cooperation, failure to keep deadlines, appointments and proper engagement prescribed by your advocate or liason as potentially counterproductive to the program may necessitate additional requirements or termination of service. Our policy requires 48-hour advance notice for appointment cancellation. Failure to do so may result in deduction of pre-paid sessions.



Termination

The client may discontinue care or :terminate this agreement at any time by written notice or to that effect and delivered in person, or by mail to Ivy's Dream LLC. Such “Notice of Termination” shall discharge Ivy's Dream from all further obligations and agreements to render services to the client. Ivy's Dream LLC reserves the right to terminate this agreement in its in its entirety at their discretion not withstanding any other terms or provisions of this agreement.



NO REFUNDS IN THE EVENT CLIENT TERMINATES AGREEMENT To encourage commitment and follow-through, Ivy's Dream LLC offers no refunds. No refunds will be made on any services or sessions. There will be NO EXCEPTIONS. Prepaid sessions cannot be altered, shared or transferred, nor can it be combined with any other program.



Cancellations:

If there is a need to cancel for any reason, we ask for a 48-hour notice. Please Understand that when you do not cancel properly or no-show for scheduled sessions it incurs a cost to us.

If you do not provide us with a 48-hour notice, or are a no show for your appointment, we may impose the following penalties:

• Loss of that session in your program package

• Loss of deposits or any advanced payments

• Any sessions paid in advance and have not been attended within 180 days will be discontinued.

• Same day cancellations will incur a loss of the scheduled session in your package or a $75.00 cancellation fee to be paid prior to your next scheduled session.


I have read and understand the service agreement and agree to abide by the above conditions provided by Ivy's Dream LLC
Yes
Yes
No
No

Student/Parent Abstract

{first_name}, Please answer the following questions as completely, honestly and as accurately as possible. The purpose of these questions is to illuminate me about you!

Student/Parent Questionnaire

{first_name}, Please answer the following questions as completely, honestly and as accurately as possible. The purpose of these questions is to further illuminate me about you! Please take your time to answer them, your progress will be saved if you log out or exit the page.

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