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Sanjoy Sathpathy MD

Custody Contract

Custody Contract

COMPLETED BY BOTH PARENTS OF CHILD

both parents initial
  • Transportation will be arranged by the parent who the child is residing with on the day of the scheduled appointment and/or agreed upon mutually between parents.
  • The parent scheduling the appointment will be responsible for canceling appointments within 24 hours and/or paying any associated late cancellation fees. Parents agree to communicate with each other when cancelling or rescheduling appointments.
  • Copays/Deductibles are to be paid at the time of session, please list only one (1) parent who will be financially responsible for all balances even if both parents are legally responsible for payment.
  • So Cal Psychiatric Care does NOT do mediation or get involved with parents financial arrangements.
By signing below, I have read and agree to the policies above A through D.


*Note: This custody contract AND pages 1 & 2 of “So Cal Psychiatric Care’s Welcome Form” (found on our website) needs to be signed separately by both parents. Please ensure this contract and /or all paperwork is completed and signed by both parents prior to child’s appointment to avoid the child’s appointment being rescheduled or cancelled. These policies are consistent with California State Laws.