Counseling Session Notice

COUNSELING SESSION NOTICE AND SERVICE AGREEMENT

Parties

Recitals

WHEREAS, Client desires to receive counseling and related professional services from Provider, and Provider represents that Provider is qualified, duly licensed where required, and able to provide such services under the terms set forth herein; and

WHEREAS, the parties intend by this Counseling Session Notice and Service Agreement to set forth the scope, payment, confidentiality and other material terms governing provision of counseling services beginning on the Effective Date set forth below.

WHEREAS, the parties agree that this Notice and Agreement controls the relationship between Client and Provider for the sessions described herein.

Effective Date

Effective Date:

Scope of Services

Provider will provide professional counseling services to Client. The specific goals, methods, expected frequency of sessions, and other elements of care are described below.

Session Details

Session Date:    Time:    Duration:

Location / Mode:

Service Modality: Individual Couples Family Telehealth

Payment Terms

Fee per Session:

Late Fee/Collection:    Provider may suspend services for unpaid fees and may recover reasonable collection and legal costs.

Cancellation and No-Show Policy

Cancellation requires at least days' notice to avoid a cancellation fee. Cancellations with less than the required notice or missed appointments may be charged: .

Term and Termination

Term Start Date:    Term End Date (if any):

Either party may terminate this Agreement for any reason upon providing days' written notice. Provider may terminate immediately for client nonpayment or behaviors that jeopardize safety or impede treatment. Upon termination, Client remains responsible for fees for services already rendered.

Confidentiality; Exceptions

All communications between Client and Provider are confidential and will not be disclosed without Client's written authorization, except as otherwise required or permitted by law. Exceptions to confidentiality include, but are not limited to: (a) suspected abuse or neglect of a child, dependent adult, or elderly person; (b) imminent risk of harm to self or others; (c) court order or other legal process; and (d) reporting obligations under applicable law. Provider will make reasonable efforts to notify Client when disclosure is required.

Records are the property of Provider. Client may request access to records; Provider will comply in accordance with applicable professional and privacy requirements and may charge a reasonable fee for copying.

Emergency Procedures

Provider is not available 24 hours per day. In the event of an emergency or immediate risk, Client should contact local emergency services or go to the nearest emergency facility. Provider will follow agreed emergency contact procedures when feasible.

Consent and Acknowledgements

By checking the boxes below and signing, Client acknowledges understanding of the terms of this Notice and Agreement and consents to the provision of services as described.

I consent to receive counseling and related services from Provider under the terms of this Agreement.

I consent to telehealth services when agreed to by Provider and understand the technical, confidentiality, and emergency limitations associated with telehealth.

I acknowledge I have read and understand the confidentiality terms above, including the listed exceptions.

Governing Law; Dispute Resolution

This Agreement shall be governed by and construed in accordance with the laws of the state specified below, without regard to conflict of laws principles. The parties agree to attempt informal resolution of disputes prior to pursuing litigation; if informal resolution fails, disputes shall be resolved in the courts of the state noted below.

Governing State:

Entire Agreement

This Notice and Service Agreement constitutes the entire agreement between Client and Provider regarding the subject matter hereof and supersedes all prior agreements, understandings, and communications, whether written or oral. Any modification must be made in writing and signed by both parties.

Acknowledgement

By signing below, the undersigned acknowledge that they have read and understand this Counseling Session Notice and Service Agreement, that they have had the opportunity to ask questions, and that they agree to be bound by its terms.

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