Healthcare Psychological Services Contract

HEALTHCARE PSYCHOLOGICAL SERVICES CONTRACT

This Psychological Services Contract (the "Agreement") is entered into by and between Provider Name: License Number: and Patient Name: .

1. Patient Information

2. Emergency Contact

3. Insurance Information

4. Scope of Services

Provider agrees to provide psychological services to Patient as described below. Services may include assessment, psychotherapy, consultation, treatment planning, and referral as appropriate.

5. Fees, Billing, and Payment

Patient agrees to pay the Provider fees for services rendered. Standard session fee: per session (unless otherwise agreed in writing). Session length: .

Cash   Check   Credit/Debit Card   Insurance Assignment

Insurance: If Patient requests Provider to bill insurance, Patient authorizes Provider to release clinical information necessary for claims submission. Patient understands insurance benefits are a contract between Patient and insurer; Provider is not party to that contract and any unpaid balance remains Patient's responsibility.

Cancellation & Missed Appointment Policy: Appointments canceled less than 24 hours prior or missed without notice may be charged a cancellation fee of unless otherwise excused for emergency or unforeseeable circumstances.

6. Confidentiality and Limits

Communications between Patient and Provider are confidential and will not be disclosed except as permitted or required by law. Limits to confidentiality include, but are not limited to: (a) reasonable belief of intent to harm self or others; (b) suspicion of abuse or neglect of a child, dependent adult, or elder; (c) court order or legal process; and (d) when Patient authorizes disclosure in writing. Provider will make reasonable efforts to discuss disclosures with Patient when feasible.

7. Records and Release of Information

Patient has the right to request access to clinical records in accordance with applicable law. Patient may authorize release of records to third parties by completing a written authorization specifying recipient, purpose, and expiration.

8. Telehealth

Telehealth: When agreed, services may be provided via telehealth. Telehealth has benefits and limitations; technology failures, privacy risks, and limitations to clinical assessment may occur. By signing this Agreement, Patient consents to receive telehealth services where clinically appropriate.

Telehealth Consent: I consent to telehealth services.

9. Risks, Benefits, and Alternatives

Psychological treatment often leads to benefits such as symptom reduction and improved functioning. However, there are no guarantees. Treatment may involve emotional discomfort, changes in relationships, or emergence of memories. Alternatives include no treatment, referral to other providers, or different modalities of care. Patient has the right to ask questions and to discontinue treatment at any time.

10. Termination and Continuity

Either party may terminate services at any time. Provider may terminate for failure to comply with this Agreement, nonpayment, or when clinically indicated. Provider will attempt to assist Patient in arranging for continuity of care and referrals when appropriate.

11. Dispute Resolution

Parties agree to attempt to resolve disputes informally. If informal resolution fails, parties may pursue mediation or other dispute resolution processes as required by applicable law. Nothing in this Agreement prevents either party from seeking urgent injunctive or other equitable relief.

12. Acknowledgment and Consent

By signing below, Patient acknowledges that they have read and understand this Agreement, have had an opportunity to ask questions, and consent to the treatment and terms described herein. Patient accepts financial responsibility as set forth above.

Financial Responsibility: I agree to be financially responsible for charges not covered by insurance.

Records Request / Release Acknowledgment: I understand rights and limitations regarding my clinical records.

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