Counseling Services Certificate

COUNSELING SERVICES CERTIFICATE

WHEREAS, Provider Name: is duly licensed and authorized to provide counseling and related behavioral health services; and

WHEREAS, Client Name: has engaged Provider for professional counseling and has attended sessions as described herein; and

WHEREAS, this certificate is issued as a formal attestation of the counseling services provided and of the terms governing those services.

Provider and Client Information

Scope of Work

Description of Services: The Provider shall deliver counseling services to the Client consisting of assessment, individual or group counseling, treatment planning, therapeutic interventions, and coordination with other care providers as necessary. Specific goals, modalities and frequency are set forth below and in the clinical record.

Service Dates and Intensity

Start Date:    End Date:    Total Number of Sessions:

Payment Terms

Fees for Services: Client agrees to pay Provider the fees described below. Provider certifies the amounts billed are accurate reflections of services rendered.

Late Payment: A late fee of or % per month, whichever is greater, may be charged on overdue balances, unless prohibited by applicable law.

Term and Termination

Term: This engagement commences on the Service Start Date provided above and continues until the Service End Date or until the services set forth are completed, unless earlier terminated.

Termination: Either party may terminate this engagement for any reason upon written notice to the other party. Notice Period (in days):

Effect of Termination: Upon termination, Provider shall provide a final statement of services rendered and the Client shall promptly remit payment for all services rendered through the effective date of termination.

Confidentiality

Provider shall maintain the confidentiality of Client information in accordance with applicable professional standards and privacy laws. Confidential information shall not be disclosed except: (a) with Client's written authorization; (b) as required by law, court order, or mandatory reporting obligations; or (c) to prevent a clear and imminent danger of serious bodily harm. Provider will document any disclosures made under subsections (b) and (c).

Certification of Services Rendered

I hereby certify that the statements contained in this certificate are true and accurate to the best of my knowledge and that the services described have been provided to the Client as indicated.

Governing Law and Entire Agreement

Governing Law: This Certificate and any dispute arising out of or relating to it shall be governed by the laws of the State of , without regard to conflict of laws principles.

Entire Agreement: This Certificate constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior agreements and understandings, whether written or oral, relating to such subject matter.

Acknowledgments

Services Completed: (check to indicate that services described above have been completed)

Liability: Provider affirms that professional liability insurance coverage is in effect for services provided under this Certificate where applicable and permitted by law.

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