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Statement of Understanding and Reunification Therapy Intake

Jason Cheney’s 2026 Mesa Valley Counseling packet: statement of understanding, fee and court terms, and the per-parent intake questionnaire.

Each parent or guardian completes their own packet. Allow about 35 minutes. Please complete this on a private computer or phone.

This form is sent over a secure connection. Please do not complete it on a shared or public computer.

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Why reunification therapy

This packet follows Mesa Valley Counseling’s Statement of Understanding for Reunification Therapy (2026). Jason Cheney, M.Ed., LPC, is a former child welfare therapist specializing in family systems, trauma, parent-child interaction, and marriage therapies. He is EMDR-trained, PCIT certified, and experienced in Trauma Systems Therapy. A child having a relationship with two healthy, skilled biological parents is the ideal. Many reparable factors lead to estrangement. Studies support this work: about 27% of Americans report estrangement from a family member. Baker (2007) and others report that children who grow up refusing or resisting contact with a parent later show higher rates of depression, substance problems, identity difficulties, and insecure attachment. The amount of conflict between parents during and after separation is the most powerful predictor of poor child mental health. Waiting years through litigation can entrench avoidant patterns and make later intervention harder.

I have read why Mesa Valley Counseling offers reunification therapy and understand the child’s wellbeing is the focus. *

Description of reunification therapy

Reunification, or reintegration, therapy is systemic, conjoint family therapy that addresses contact resistance/refusal or estrangement between a parent and child. It is often court-ordered when a child resists contact with a caregiver, and may also be sought by co-parents who want to ease a child’s distress over transitions. The goal is to rebalance the family system so the child can make and maintain healthy relationships with each caregiver. The therapist serves the child’s need for as many healthy emotional anchors as possible. Usually no single person is solely at fault. Waiting until a child is “ready” for contact is paradoxical: without contact the relationship often becomes more strained. A critical pre-condition is that the court has already decided contact will happen; the remaining question is how. The entire family system must participate, with open communication among involved professionals (individual therapists, GAL, parenting coordinator, and others). In reunification therapy, the family is the client. Reluctance may come from a never-established relationship, high-conflict or violent parent interactions or maltreatment, one parent undermining the other, or a child aligning with one parent to relieve loyalty conflict.

I understand reunification therapy is a structured clinical process for the family system, not legal advice or a custody evaluation. *

What to expect, roles, and phases

Work may include individual sessions with the child or either parent, sibling sessions, meetings with other family members, joint parent coaching, and conjoint sessions. Gradual exposure can include calls, messaging, video, handwritten notes, exchanging photos or belongings, and parent-child outings that may last hours or include an overnight. Custodial / aligned parent: schedule promptly at the recommended frequency; treat attendance as mandatory and use appropriate consequences for non-attendance; contact the therapist if resistance occurs; do not discuss session content or coach the child; do not share your concerns about the process with the child; encourage the child to follow recommendations; expect some anxiety or mixed emotion. Reunifying parent: acknowledge the current difficulty; be patient and follow the therapist’s pace; accept feedback without defensiveness or blame; listen, apologize when appropriate, and earn trust through actions. Children: attend as scheduled; consider that neither parent is all good or all bad; trust that contact advances only in small, supported steps; do not discuss sessions with the custodial parent in ways that interfere with the work. Phase 1: separate parent intakes, 2–4 child sessions, and record review (telehealth or in person). Phase 2: joint parent-child sessions (often 6–20+) that may include EMDR elements when appropriate. Phase 3: spaced or off-site sessions under guidance. Phase 4: updates or recommendations to parents, attorneys, or the court when goals are met or treatment ends. Jason Cheney remains objective and is not aligned with either parent. He may empathize with and also challenge the child, coach the reunifying parent, and report progress when ordered. The therapist directs frequency, when to move from individual to joint work, and when to leave the office. If a parent unilaterally ends court-ordered work, a summary letter to the court and attorneys may be required. Treatment ends when the child can safely continue the relationship without structured therapy, or when significant barriers persist despite good-faith participation.

I understand my role, the four phases, and that the therapist—not either parent—directs pacing and session format. *

Communication and court-related limits

Clinical email and portal messages are limited. If you have a concern, email the therapist and copy the other parent to request a meeting or call. Process updates are sent to both parents; reply-all is expected. That joint-communication rule does not apply when the court has verified domestic violence or there is an active protective order—then contact is separate or through counsel. Third-party contact (attorneys, GAL, other clinicians, school) requires a signed release. Attorney contact is made jointly whenever possible. Time on third-party communication is billed to the parent responsible for payment. Jason Cheney and Mesa Valley Counseling cannot provide legal advice. Nothing written or spoken is legal advice, legal information, or the practice of law, including progress updates or recommendations in court-ordered cases.

I agree to joint (reply-all) communication except in verified domestic-violence or protective-order cases, and I understand this is not legal advice. *

Confidentiality

Reunification work has important limits on confidentiality under Colorado law, ACA ethics, and HIPAA where applicable. 1. Both parents sign releases for their attorneys. 2. The parent with legal custody signs a release for the child’s individual therapist, school counselor, or psychiatrist. 3. Information shared under a release may be re-disclosed by the recipient. 4. Information may be disclosed to the court or counsel in a legal proceeding and then is generally no longer HIPAA-protected. 5. Case consultation with other qualified clinicians may include full case detail, with identity protected as much as possible. 6. Jason Cheney is a mandated reporter of suspected child abuse or neglect, elder abuse, and imminent harm to self or others. A report is a legal duty, not a finding of fault. 7. There is generally no confidentiality between parents. Messages sent without copying the other parent will be redirected jointly, except in safety or protective-order cases. 8. If Mesa Valley Counseling must defend an ethics complaint, board investigation, or legal claim, case details may be shared with counsel or the licensing board. 9. Clients may not record sessions. The therapist records only after notice and consent, and only for training, supervision, or quality assurance.

I understand these confidentiality limits, including joint parental communication, court disclosure, consultation, and mandated reporting. *

I will not record any session or communication. I understand the therapist records only with prior notice and consent. *

Payment and fee policies

Reunification sessions are $200 per 50–60 minutes (billed as a full hour), including individual, joint, parent-only, and child-only meetings. Brief scheduling messages under 15 minutes are not billed. Extended calls, document review, clinical email beyond scheduling, case plans, progress summaries, special reports, consultations, and travel to off-site Phase 3 appointments are billed at $200 per hour in 15-minute increments. Use email for scheduling only. Texts and social media are not used for clinical or scheduling contact. Court or deposition appearance requires a properly served subpoena and full prepayment at least 30 days ahead: $2,000 for a half-day (4 hours or less) and $4,000 for a full day, paid by the party issuing the subpoena (split equally if both parties issue one). Non-remote travel is billed at the session rate. No appearance occurs without prepaid fees. An initial retainer of $2,000 to $5,000 is required before services begin, set by the therapist based on complexity, and applied to future fees. Each parent is individually responsible unless a court order or written agreement says otherwise. A credit card authorization is required and is charged after each session or billable time. Insurance typically does not cover reunification or court-related services. There are no refunds for retainers, deposits, canceled court dates, early termination, or dissatisfaction. Late balances incur a 20% fee each week. Collection costs are the responsible party’s duty and may require disclosing information to a collector. Returned checks are $35 plus late fees. Missed sessions, cancellations with less than 48 hours’ notice, and arrivals more than 15 minutes late are charged the full $200 session fee.

I have read the $200 session fee, retainer, court-appearance fees, credit-card billing, and 48-hour cancellation policy, and I agree to pay those fees in full. *

I understand Mesa Valley Counseling does not offer refunds for retainers, holding fees, completed services, canceled court dates, or dissatisfaction. *

I understand late balances may add 20% each week and that collection may include associated costs. *

Statement of understanding acknowledgments

Initial each statement. These confirm informed consent to participate, including the unique structure, limitations, risks, benefits, and expectations of reunification therapy. By signing you attest that you have read this document in its entirety and agree to the contractual and financial terms with Mesa Valley Counseling.

I authorize Mesa Valley Counseling to provide reunification therapy services. *

I understand Mesa Valley Counseling may consult with other professionals, and I give permission for those discussions. *

I understand Mesa Valley Counseling may need to reveal case details to defend itself against an ethics complaint, investigation, or legal action. *

I understand materials I or others provide for review will not be returned, so I will not send original documents. *

I understand holding fees paid in advance for settlement conferences, depositions, or testimony are non-refundable deposits. *

Client name(s) covered by this agreement *

Your legal name *

Date you are signing the statement of understanding *

Your mailing address or other contact notes

Email *

Phone *

Electronic signature on the statement of understanding *

Type your full legal name. Checking the box applies your electronic signature. This page does not record handwriting, a mouse path, or a finger tracing.

Typed legal nameI agree that typing my name is my electronic signature. It has the same legal effect as signing on paper under the federal ESIGN Act and the Colorado Uniform Electronic Transactions Act.

Intake — who is completing this form

Each parent completes this intake separately. Fax copies may still be sent to (970) 787-6655 if needed. Office: 3198 F Road, Suite 204, Grand Junction, CO 81504 · (970) 462-9944 · jasonjcheney@gmail.com.

Your name (the parent completing this intake) *

Date *

Which parent are you? *

Custodial / preferred / aligned parentEstranged / rejected / target parentOther

If other, describe your role

Child or children involved

Start with one child. Use Add another child if more than one child is in this case.

Child 1

Name *

Age *

Date of birth *

Grade / school

Add another child if you need more than one. The first stays on the page.

Concerns

Primary concerns leading to contact resistance or refusal (check all that apply) *Child refuses or strongly resists contact with the other parentNo contact for a period of months or yearsAllegations of abuse or neglect by one parentHigh-conflict co-parenting / badmouthing / triangulationPrior positive relationship now damagedChild shows polarized views (all-good / all-bad)Other

If there has been no contact, for how many months or years?

If there are abuse or neglect allegations, specify who alleges what

If other concern, describe

In your view, what are the main factors contributing to the child’s reluctance or resistance? *

Child’s current functioning and views

Child’s expressed feelings about the other parent (quotes if known) *

Symptoms or behaviors you have noticed (anxiety before visits, withdrawal, anger, school issues)

Does the child speak positively about the other parent in any context? *

YesNoRarely

Safety and risk screening

Have there been substantiated or credible allegations of abuse, neglect, domestic violence, or substance issues involving either parent? *

NoYes

If yes, details, dates, and outcomes

Any current safety concerns (substance use, mental health crisis, threats)? *

NoYes

If yes, describe current safety concerns

Has Child Protective Services or an equivalent agency been involved? *

NoYes

If yes, case status

Any restraining or protective orders? *

NoYes

If yes, protective-order details

Co-parenting dynamics

How would you describe communication with the other parent currently (email only, hostile, neutral)? *

Do you share important child information (school, medical, activities)? *

YesNoSometimes

Examples of undermining or supportive behaviors you have observed from the other parent

Goals, expectations, and additional information

A customized meeting schedule is prepared after intake. The sample calendar in the paper packet is an example only and is not signed here.

Specific goals for reunification therapy, and what success would look like in 3–6 months (for example regular unsupervised visits, reduced anxiety, a more balanced view) *

Any fears or concerns about the process (too slow or fast, pressure on the child)

Are you committed to full participation, including individual, co-parenting, and joint sessions as recommended? *

YesUnsure

If unsure, please explain

Current mental health or substance treatment for you or the child

Other professionals involved (therapists, GAL, evaluator, parenting coordinator)

Anything else the therapist should know at intake?

I certify that this information is accurate to the best of my knowledge. I understand reunification therapy is child-centered, requires active effort from both parents, and may involve court reporting on cooperation and progress. *

Typed name *

Date *

Electronic intake signature *

Type your full legal name. Checking the box applies your electronic signature. This page does not record handwriting, a mouse path, or a finger tracing.

Sign by typing your legal name and checking the consent box, then submit the form.

58 required items are still blank, including “I have read why Mesa Valley Counseling offers reunification therapy and understand the child’s wellbeing is the focus.”. You can still press Submit — the next screen will say exactly what is missing.

Statement of Understanding and Reunification Therapy Intake

Why reunification therapy

Description of reunification therapy

What to expect, roles, and phases

Communication and court-related limits

Confidentiality

Payment and fee policies

Statement of understanding acknowledgments

Intake — who is completing this form

Child or children involved

Child 1

Contact, legal status, and court involvement

Concerns

Relationship history and your contribution

Child’s current functioning and views

Safety and risk screening

Co-parenting dynamics

Goals, expectations, and additional information