Contracts & Forms

Our most frequently requested contracts are available for download below. Feel free to use and review them, and don't hesitate to call if you have questions about any of the content.

Kirsten Lysne, PhD

Coaching Agreement (742.35 KB)
Mediation Agreement (731.2 KB)
Child Consultant Agreement (818.4 KB)
Therapy Agreement (636.5 KB)
Consulting Expert Agreement (1 MB)
Release of Information Form - HIPAA (980.63 KB)

Peggy Cottrell, MA, LMFT

Child Consultant Agreement (825.03 KB)
Coaching Agreement (740.49 KB)
Mediation Agreement (729.59 KB)
PC Fee Agreement (922.62 KB)
PTE Agreement (1.04 MB)
Therapy Agreement (636.5 KB)
Release of Information Form - HIPAA (679.12 KB)

Michael Goldfarb, MSW, LICSW

Child Consultant Agreement (309.74 KB)
Coaching Agreement (242.8 KB)
Custody Evaluation Agreement (1.04 MB)
Mediation Agreement (731.54 KB)
PC Fee Agreement (867.76 KB)
Release of Information Form - HIPAA (504.61 KB)

Matthew Shore, MSW, LICSW

Child Consultant Agreement (263.9 KB)
Coaching Agreement (294.47 KB)
Custody Evaluation Agreement (1012.33 KB)
Mediation Agreement (731.48 KB)
PC Fee Agreement (614.42 KB)
PTE Agreement (830.79 KB)
Release of Information Form - HIPAA (1001.8 KB)

Services with Multiple Providers

Child Inclusive Mediation Agreement (790.03 KB)
Reunification Services Agreement (271.23 KB)
SENE Agreement (335.27 KB)
SENE Confidentiality Agreement (58.17 KB)

Contact Us

Moxie, Inc.

We've moved!

9800 Shelard Parkway, Suite 340
Plymouth, MN 55441

PHONE: 763-444-2240
FAX: 763-444-2241

admin@moxieinc.com

MOXIE:

The ability to face difficulty
with spirit

Links

Parenting Consultant Stipulation & Order on Mediation Center Website

Forms

Payment Remittance Form (105.32 KB)
Release of Information Form - General (567.04 KB)