Client Intake Rights Forms

CLIENT INTAKE RIGHTS FORMS

Parties and Recitals

This Client Intake Rights Agreement (the Agreement) is entered into by and between Client Name: and Service Provider: .

WHEREAS, the Service Provider conducts intake, assessment, and related services and will collect certain personal and health-related information from the Client to evaluate needs and provide services; and

WHEREAS, the parties wish to set forth the Client's intake rights, the scope of services to be provided, payment terms, confidentiality protections, and other contract terms governing the intake relationship between the parties; and

WHEREAS, the parties intend that this written Agreement memorialize those rights and obligations as of the Effective Date below.

Scope of Work

The Service Provider will perform intake, assessment, referral, and related administrative services described below. The Scope of Work defines the initial intake processes, information collection, and any follow-up activities authorized by the Client.

Client Rights Acknowledgment

The Client acknowledges the following rights related to intake and recordkeeping. The Client must initial or check each applicable statement to confirm receipt and acknowledgement.

Payment Terms

The Client agrees to the following payment terms for any services or administrative fees associated with intake, where applicable.

Payment shall be due in accordance with the schedule above. Unpaid amounts shall accrue late fees as stated and may be subject to collection costs and interest to the fullest extent permitted by law.

Term and Termination

This Agreement commences on Start Date: and, unless earlier terminated as provided herein, will end on End Date: .

Either party may terminate this Agreement without cause upon written notice given at least Notice Period (days): days prior to termination. Termination for cause may occur immediately upon written notice where a material breach has occurred and remains uncured after a reasonable cure period.

Upon termination, the Client remains responsible for all fees and charges incurred through the effective date of termination and any reasonable wind-down costs authorized in advance.

Confidentiality

The Service Provider shall maintain as confidential all Client intake records, personal information, and communications, and shall not disclose such information except:

• as authorized in writing by the Client;
• as necessary to provide the services described in this Agreement;
• where disclosure is required by law, including mandatory reporting of abuse or imminent risk of harm, or pursuant to a valid court order; or
• to contractors or agents bound by confidentiality obligations no less restrictive than those herein.

The Service Provider will take commercially reasonable measures to maintain the security and integrity of Client records and will notify the Client of any unauthorized access to protected information in accordance with applicable law.

Governing Law and Dispute Resolution

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

Any dispute arising under or in connection with this Agreement will be resolved by the parties using good-faith negotiation. If unresolved, the parties may agree to mediation or pursue remedies in courts of competent jurisdiction within the stated governing state.

Representations, Warranties and Indemnity

Each party represents and warrants that it has the full right, power, and authority to enter into this Agreement and to perform its obligations. The Client agrees to defend, indemnify, and hold harmless the Service Provider from any claim, loss, or liability resulting from the Client's breach of this Agreement or from inaccurate information provided by the Client, except to the extent caused by the Service Provider's gross negligence or willful misconduct.

Entire Agreement

This Agreement, together with any exhibits or signed attachments, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior or contemporaneous oral or written agreements and understandings. No modification of this Agreement will be effective unless in writing and signed by both parties.

Acknowledgment and Certification

By signing below, the Client certifies that they have received, read, and understand their intake rights as described in this Agreement, have had the opportunity to ask questions, and agree to the terms herein. The Service Provider certifies that it has explained the Client's intake rights, confidentiality exceptions, and complaint procedures.

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