Client Consent Form

CLIENT CONSENT FORM

This Client Consent Form (the "Agreement") is entered into by and between:

Client Name:

Service Provider Name:

WHEREAS

WHEREAS, the Client desires to engage the Service Provider to perform certain services as described herein, and the Service Provider is willing to perform such services under the terms and conditions set forth in this Agreement.

WHEREAS, the parties wish to set forth the scope of the services, payment terms, confidentiality obligations and other material terms governing their relationship effective as of: Effective Date:

WHEREAS, the Client acknowledges that informed consent for the services, use of information, and certain operational actions (such as recording or third-party disclosures) is required and hereby provides such consent in accordance with the terms below.

SCOPE OF WORK

CONSENTS AND AUTHORIZATIONS

The Client hereby expressly consents to the following (check all that apply):

Provision of Services — The Client authorizes the Service Provider to perform the Scope of Work described above and to take reasonable actions necessary to provide those services.

Use and Processing of Client Information — The Client consents to collection, storage and processing of personal and business information reasonably necessary for performance, billing and recordkeeping, subject to the Confidentiality clause below.

Audio/Visual Recording — The Client authorizes audio and/or video recording of sessions or interactions when reasonably required for service quality, training, or documentation, except where prohibited by law.

Limited Third-Party Disclosure — The Client authorizes disclosure of information to independent contractors or third parties when necessary for performance, provided such parties are contractually bound to confidentiality consistent with this Agreement.

PAYMENT TERMS

Fee Amount: $

Invoices are due within days of invoice date. Late payments shall incur a late fee of on any unpaid balance, together with all costs of collection, including reasonable attorneys' fees.

TERM AND TERMINATION

Term Commencement Date:

Term Expiration Date (if any):

Either party may terminate this Agreement for convenience upon prior written notice to the other party no less than days prior to the effective termination date. Termination for cause is permitted where the other party materially breaches this Agreement and fails to cure within a reasonable period, not to exceed thirty (30) days after written notice specifying the breach.

CONFIDENTIALITY

Each party agrees that it will hold in strict confidence all Confidential Information disclosed by the other party and will not use such Confidential Information except as necessary to perform under this Agreement. "Confidential Information" includes non-public business, financial, technical and client-related information, whether oral, written or electronic.

Confidentiality obligations do not apply to information that: (a) is or becomes publicly available through no fault of the receiving party; (b) was rightfully in the receiving party's possession prior to receipt; (c) is received from a third party without breach of any obligation of confidentiality; or (d) is required to be disclosed by law, regulation, or valid court order, provided the disclosing party is given prompt notice and, where permitted, an opportunity to seek protective measures.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to its conflict of laws principles.

ENTIRE AGREEMENT

This Agreement, together with any exhibits or attachments expressly incorporated herein, constitutes the entire agreement between the parties with respect to its subject matter and supersedes all prior and contemporaneous agreements, proposals, negotiations and communications, whether written or oral. Any amendment to this Agreement must be in writing and signed by both parties.

REPRESENTATIONS, ACKNOWLEDGMENTS AND CERTIFICATIONS

By signing below, the Client represents and warrants that the information provided in this form is true and complete to the best of the Client's knowledge; that the Client has the authority to enter into this Agreement; and that the Client has read, understands, and voluntarily accepts the terms and consents described herein.

Client Acknowledgement — I acknowledge and consent to the terms of this Agreement and the consents indicated above.

CONTACT INFORMATION

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