Chest. Cnty. Ct. Comm. Plea. R., form 17
I,_________________, the undersigned applicant, hereby certify that I possess the minimum qualifications to serve as a Parenting Coordinator as established by Pa.R.Civ.P. 1915.11-1(b)(1),(2), as follows:
1. _____I have the following professional degree:_________________from (Institution and
date granted):__________
2. _____I am licensed to practice in the Commonwealth of Pennsylvania as a_________________. My license number is______.
_____My license is in good standing.
_____I have never been subject to professional discipline. (If Applicant has been subject to discipline, provide details on separate sheet).
_____I have_____years of experience in dealing with families involved in child custody matters, as follows: (or attach CV):
______
______
______
3._____I have obtained the special training required by the Rule and have attached verification for each training:
hours in the Parenting Coordination process, of which 2 or more hours were specific to Pennsylvania PC practice.
Date of training:_________________
Provider:_________________
_____hours of Family mediation (or hours of non-specific mediation training and hours of Family Mediation conducted).
Date of training:_________________
Provider:_________________
_____hours of Domestic Violence training.
Date of training:_________________
Provider:_________________
4. I understand that to remain qualified as a Parenting Coordinator in each 2 year period after March 1, 2019, I must take a minimum of 10 additional continuing education credits, of which at least 2 must be on domestic violence.
5.I maintain Professional Liability insurance of $______, which coverage expressly covers me for serving as a Parenting Coordinator. The Declaration page showing the foregoing is attached.
6.I acknowledge that I may not charge more than $350 per hour (although I may charge less), nor require more than a $1,500 initial retainer. My hourly rate for Parenting Coordination is: $______.
7.I acknowledge I must accept one pro bono PC appointment for every 2 fee-generating appointments in this judicial district/county, up to 12 hours per pro bono case. I understand that it is my responsibility to advise the court upon acceptance of the second appointment. I further understand that failing to accept a pro bono assignment or to notify the Court is grounds for removal from the roster maintained by this county. My obligation to provide pro bono work is ongoing and does not expire in the event I do not receive a pro bono case.
8._____I have read Pa.R.Civ.P. 1915.11-1 and understand the scope (and) limits of my authority and the procedures which I must follow when appointed as a Parenting Coordinator.
9._____I acknowledge that I have read the Guidelines for Parenting Coordination promulgated by the American Psychological Association and Association of Family and Conciliation Court. https://www.apa.org/practice/guidelines/parenting-coordinationhttps://afccnet.org/Resource-Center/Practice-Guidelines
I swear or affirm that the foregoing statements are true and correct.
APPLICANT:
Name (printed)_________________
Signature_________________
Date:_________________
FOR OFFICIAL USE ONLY
Qualifications Reviewed by:______(initials)
Place application on Roster:______ ______
Yes
No
If No, state reasons:
_______
_______
J.
Chest. Cnty. Ct. Comm. Plea. R., form 17