Client Journal Request Form

CLIENT JOURNAL REQUEST FORM

Client Name:     Client Contact Phone:

Service Provider Name:     Provider Contact Email:

Recitals

WHEREAS, Client engages Provider to prepare a written client journal (the "Journal") documenting sessions, observations, progress notes, and related materials as requested by Client and as described in this form; and

WHEREAS, Provider possesses the professional capacity and facilities to create, compile, and deliver the Journal in accordance with the Scope of Work and Payment Terms set forth below; and

WHEREAS, the parties desire to set forth their respective obligations, confidentiality protections, and governing terms in a binding agreement memorialized by the signatures below.

Journal Details & Request Specifications

Format requested: Digital (PDF) Printed bound copy Raw session notes

Scope of Work

Payment Terms

Total Fee:    Deposit Required:    Balance Due:

Payment schedule and method:

Late payment: A late fee of percent per month (or the maximum allowed by law) will accrue on overdue amounts beginning 30 days after the invoice due date. Client is responsible for reasonable collection costs and attorney's fees incurred to enforce payment.

Term and Termination

Effective Start Date:    Anticipated Completion Date:

Either party may terminate this request for material breach if the breach is not cured within days after written notice. Termination by Client without cause after work has commenced shall not relieve Client of payment for work performed to the date of termination plus any reasonable wind-down costs.

Confidentiality

Provider will treat all client-provided materials and any portions of the Journal that contain personal, health, or proprietary information as Confidential Information. Provider will not disclose Confidential Information to third parties except as required by law or with Client's prior written consent. Provider shall implement reasonable administrative and technical safeguards to protect Confidential Information from unauthorized access, use, or disclosure.

Notwithstanding the foregoing, Client authorizes Provider to use non-identifying, aggregated excerpts for internal quality assurance unless Client expressly indicates restriction below:

Restrict use for QA/publication: Client restricts publication or non-identifying use

Delivery and Acceptance

Delivery method:

Client shall notify Provider of any material defects or deficiencies in the delivered Journal within days of delivery. If Client does not provide timely notice, the Journal will be deemed accepted and payment obligations unaffected.

Governing Law; Entire Agreement

This Agreement shall be governed by and construed in accordance with the laws of the state indicated by the parties below. Any dispute arising under or relating to this Agreement shall be resolved in the courts of that state unless the parties mutually agree otherwise in writing.

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

Acknowledgment and Certifications

By signing below, Client certifies that Client has authority to request the Journal and provide the materials supplied to Provider and that the information provided in this form is accurate. Provider certifies that the Journal will be prepared consistent with the Scope of Work and in accordance with applicable laws and professional standards.

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