Fill and Sign the Independent Contractor Application 497337199 Form

INDEPENDENT CONTRACTOR COUNSELOR AGREEMENT THIS AGREEMENT made and entered into on the date last written below, by and between       (hereinafter "Employer"), and       , an independent contractor (hereinafter "Counselor"); WHEREAS, the Employer desires to retain the services of Counselor, and Counselor desires to render services to the Employer, upon the terms and conditions hereinafter stated: NOW, THEREFORE, the parties hereto, intending to be legally bound hereby, do hereby promise and agree as follows: SECTION 1 – SCOPE OF DUTIES TO BE PROVIDED 1.1 Term . Employer agrees to hire Counselor, at will, for a term commencing on             , 20       and continuing until terminated in accordance with Section 4 of this agreement. 1.2 Duties . Counselor agrees to perform work for the Employer on the terms and conditions set forth in this agreement and agrees to devote all necessary time and attention (reasonable periods of illness excepted) to the performance of the duties specified in this agreement. Counselor's duties shall include the following:             . Counselor further agrees that in all aspects of such work, Counselor shall comply with the policies, standards, regulations of the Employer from time to time established, and shall perform the duties assigned faithfully, intelligently, to the best of his/her/their ability, and in the best interest of the Employer. SECTION 2 – CONFIDENTIALITY 2.1 Confidentiality . Counselor acknowledges and agrees that property owned by Employer, including amounts paid therefore, patient lists, and other Employer data and information related to its business (hereinafter collectively "Confidential Information") are valuable assets of the Employer. Except for disclosures required to be made to advance the business of the Employer and information which is a matter of public record, Counselor shall not, during the term of this Agreement or after the termination of this Agreement, disclose any Confidential Information to any person or use any Confidential Information for the benefit of Counselor or any other person, except with the prior written consent of the Employer. Employer understands that certain Confidential Information may be required to be disclosed to certain individuals: directors, officers, employees, agents, or - 1 – advisors (collectively, Representatives) of Counselor. Counselor shall maintain records of the persons to whom Confidential Information is distributed, will inform all such persons of the confidential nature of the information, will direct them to treat such information in accordance with this agreement, will exercise such precautions or measures as may be reasonable in the circumstances to prevent improper use of Confidential Information by them, and will be responsible for any breaches by them of the provisions of this agreement. The term “confidential information” does not include information that is or becomes publicly available (other than through breach of this Agreement) or information that is or becomes available to Counselor on a non- confidential basis, provided that the source of such information was not known by Counselor (after such inquiry as would be reasonable in the circumstances) to be bound by a confidentiality agreement or other legal or contractual obligation of confidentiality with respect to such information. In the event that Counselor or any of Counselor’s representatives, assigns, or agents are requested or required by law or legal process to disclose any of the Confidential Information, the party required to disclose such information shall provide Employer with prompt oral and written notice before making any disclosure. In addition, Confidential Information may be disclosed to the extent required in the course of inspections or inquiries by federal or state regulatory agencies to whose jurisdiction Counselor is subject and that have the legal right to inspect the files that contain the Confidential Information, and Counselor will advise Employer promptly upon such disclosure. 2.2 Return of Documents . Counselor acknowledges and agrees that all originals and copies of records, reports, documents, lists, plans, memoranda, notes and other documentation related to the business of the Employer or containing any Confidential Information shall be the sole and exclusive property of the Employer, and shall be returned to the Employer upon the termination of this Agreement or upon the written request of the Employer. 2.4 No Release . Counselor agrees that the termination of this Agreement shall not release Counselor from any obligations under Section 2.1 or 2.2. SECTION 3 – COMPENSATION 3.1 Compensation . In consideration of all services to be rendered by Counselor to the Employer, the Employer shall pay to said       the amount of $       per hour week bi-weekly month year other       . 3.2 Withholding; Other Benefits . Compensation paid pursuant to this Agreement shall not be subject to the customary withholding of income taxes and other employment taxes. - 2 – Counselor shall be solely responsible for reporting and paying any such taxes. The Employer shall not provide Counselor with any coverage or participation in the Employer's accident and health insurance, life insurance, disability income insurance, medical expense reimbursement, wage continuation plans, or other fringe benefits provided to regular employees. SECTION 4 - TERMINATION 4.1 Termination at Will . This Agreement may be terminated by the Employer immediately, at will, and in the sole discretion of Employer. Counselor may terminate this Agreement upon       days written notice to Employer. This Agreement also may be terminated at any time upon the mutual written agreement of the Employer and Counselor. SECTION 5 - INDEPENDENT CONTRACTOR STATUS 5.1 Counselor acknowledges that he/she is an independent Contractor and is not an agent, partner, joint venturer nor employee of Employer. Counselor shall have no authority to bind or otherwise obligate Employer in any manner beyond the terms of this Agreement, nor shall Counselor represent to anyone that it has a right to do so. Counselor further agrees that in the event that the Employer suffers any loss or damage as a result of a violation of this provision Counselor shall indemnify and hold harmless the Employer from any such loss or damage. 5.2 Assignment. The Counselor shall not assign any of his/her rights under this agreement, or delegate the performance of any of his/her duties hereunder, without the prior written consent of the Employer. SECTION 6 - REPRESENTATIONS AND WARRANTIES OF COUNSELOR 6.1 Counselor represents and warrants to the Employer that there is no employment contract or other contractual obligation to which Counselor is subject, which prevents Counselor from entering into this Agreement or from performing fully Counselor's duties under this Agreement. 6.2 Counselor represents that he/she is licensed by the appropriate licensing agency for the       profession and that he/she is in good standing with such agency. SECTION 7 - MISCELLANEOUS PROVISIONS 7.1 The provisions of this Agreement shall be binding upon and inure to the beneft of the heirs, personal representatives, successors and assigns of the parties. Any provision hereof which imposes upon Counselor or Employer an obligation after termination or expiration of - 3 – this Agreement shall survive termination or expiration hereof and be binding upon Counselor or Employer. 7.2 No waiver of any provision of this Agreement shall be deemed, or shall constitute, a waiver of any other provision, whether or not similar, nor shall any waiver constitute a continuing waiver. No waiver shall be binding unless executed in writing by the party making the waiver. 7.3 This Agreement shall be governed by and shall be construed in accordance with the laws of the State of       . 7.4 This Agreement constitutes the entire agreement between the parties pertaining to its subject matter and supersedes all prior contemporaneous agreements, representations and understandings of the parties. No supplement, modifcation or amendment of this Agreement shall be binding unless executed in writing by all parties. 7.5 Severability. If any provision of these policies and regulations or the application thereof to any person or circumstances is held invalid, such invalidity shall not affect other provisions or applications of these policies and regulations which can be given effect without the invalid provision or application, and to this end the provisions of these policies and regulations are severable. In lieu thereof, there shall be added a provision as similar in terms to such illegal, invalid and unenforceable provision as may be possible and be legal, valid and enforceable . WITNESS OUR SIGNATURES, this the       day of       , 20       . ___________________________ EMPLOYER ___________________________ COUNSELOR - 4 –