Healthcare Therapeutic Services Agreement

HEALTHCARE THERAPEUTIC SERVICES AGREEMENT

This Therapeutic Services Agreement (Agreement) is entered into between the Provider listed below and the Patient identified herein for the provision of behavioral health and therapeutic services subject to the terms and conditions set forth. Provider and Patient acknowledge that this Agreement is a legally binding document establishing the professional relationship, scope of services, and the rights and obligations of the parties.

Provider Identification

Patient Information

Date of Birth:

Female    Male    Non-binary/Other    Prefer not to say

Insurance Information (if applicable)

Presenting Concerns and Services

Term of Services: Services will commence on and will continue until terminated in accordance with this Agreement or until the anticipated end date of .

Fees, Billing and Collections

Self-pay    Bill insurance (patient authorizes release of information to insurer)    Sliding scale / reduced fee

Patient acknowledges responsibility for payment of fees incurred for services rendered when not covered by insurance or when insurance denies payment. Balances not paid within thirty (30) days may be subject to collection procedures. Provider will attempt to provide an estimate of expected patient responsibility but such estimates are not guarantees of coverage or payment.

Cancellation and No‑Show Policy

Appointments missed without at least 24 hours advance notice or cancelled after the provider's cancellation deadline may be charged at the full session rate. Repeated no-shows or late cancellations may result in termination of services.

I acknowledge that I have read, understand, and will comply with the cancellation and no-show policy.

Medical and Mental Health History

Consent to Treatment; Risks and Benefits

Patient consents to receive therapeutic services from Provider. Provider has explained the nature, purpose, and potential benefits of treatment, as well as reasonably foreseeable risks including, but not limited to, emotional distress, temporary increase in symptoms, and the potential for changes in interpersonal relationships. There are no guarantees regarding outcomes.

I voluntarily consent to the provision of therapeutic services as described above and understand that I may withdraw consent at any time by notifying Provider in writing.

Telehealth Services

Telehealth may be used for all or part of the services. Telehealth carries specific risks including technology failure, reduced privacy in the patient's environment, and limitations of remote assessment. Patient accepts responsibility for ensuring a private location and appropriate technology when participating in telehealth.

I consent to telehealth services where clinically appropriate.

Confidentiality, Privacy and Limits

All information disclosed within sessions and the records thereof are confidential and may not be revealed without written permission, except for legal exceptions including: (1) suspected child, elder, or dependent adult abuse or neglect; (2) imminent risk of serious harm to self or others; (3) court order or other legal compulsion; (4) when billing insurers and health care payors as described in this Agreement. Provider will make reasonable efforts to limit disclosures to the minimum necessary.

HIPAA Authorization and Release of Information

By signing below, Patient authorizes Provider to use and disclose protected health information as necessary for treatment, payment, and health care operations, and to communicate with the patient's insurer regarding claims. Patient further authorizes disclosure to designated individuals when necessary for care coordination as indicated below.

Patient understands that this authorization is voluntary and may be revoked in writing, except to the extent that Provider has already acted in reliance on the authorization. Revocation does not affect disclosures already made under the authorization while it was in effect.

Emergency Procedures and Coordination of Care

In emergencies, Provider will take reasonable steps to ensure patient safety, which may include contacting emergency services, emergency contacts, or arranging hospitalization. Patient consents to reasonable coordination of care with other healthcare providers when clinically indicated.

Termination of Services

Either party may terminate this Agreement at any time with written notice. Provider may terminate services without prior notice if the patient’s behavior is unsafe, disruptive, or violates practice policies. Fees for services rendered and any unpaid balances shall remain due upon termination.

Acknowledgment and Certification

Patient certifies that the information provided in this Agreement is true and complete to the best of the patient’s knowledge. Patient acknowledges receipt of a privacy notice describing Provider’s policies regarding the use and disclosure of protected health information and understands patient rights regarding access, amendment, and accounting of disclosures.

I acknowledge receipt of the Provider's privacy notice and understand my rights.

Signatures

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