Mental Health Services Agreement

MENTAL HEALTH SERVICES AGREEMENT

This Mental Health Services Agreement (Agreement) is entered into between Provider Name: and Client Name: .

RECITALS

WHEREAS, Provider is a licensed mental health professional authorized to provide psychotherapy, assessment, and related clinical services in the jurisdiction specified by the parties; and

WHEREAS, Client seeks to engage Provider to deliver mental health services as described herein and agrees to comply with the terms and conditions set forth in this Agreement; and

WHEREAS, the parties intend for this Agreement to define the scope of services, payment terms, confidentiality obligations, and other material rights and obligations between them.

SCOPE OF SERVICES

CLIENT AND PROVIDER RESPONSIBILITIES

Client agrees to attend scheduled sessions, participate in treatment planning, and provide accurate and complete information concerning health status and history. Client emergency contact: Phone: .

Provider will deliver services in a professional manner consistent with applicable standards of care, maintain clinical records, and coordinate care with other providers upon Client request or as necessary for treatment continuity.

PAYMENT TERMS

If a third-party payer (insurance) will be billed, Client must provide accurate insurance information and an Authorization for Release of Information if required. Client remains financially responsible for all charges not covered or paid by third parties.

CANCELLATION, NO-SHOW, AND LATE ARRIVAL

TERM AND TERMINATION

This Agreement commences on Start Date: and continues until End Date: or until terminated pursuant to this section.

Either party may terminate this Agreement for any reason by providing written notice to the other party at least Notice Period: prior to the intended termination date. Provider may terminate immediately if Client poses an imminent risk to self or others or breaches material terms of this Agreement.

CONFIDENTIALITY

Provider shall maintain the confidentiality of Client communications and records in accordance with applicable law and professional ethical standards. Client records shall not be released without Client's written authorization, except as required or permitted by law. Permitted exceptions to confidentiality include:

• Reasonable belief of imminent risk of harm to Client or others (duty to warn/protect);
• Reasonable suspicion of abuse or neglect of a child, dependent adult, or elder;
• Court order compelling disclosure;
• When Client has signed an authorization permitting release of specified records to designated entities.

TELEHEALTH AND COMMUNICATION

Client consents to telehealth services where clinically appropriate. Client acknowledges limits of confidentiality for electronic communication and agrees to follow Provider instructions for secure communication. Telehealth consent: I consent to telehealth services.

RECORDS AND RETENTION

Provider will maintain clinical records in accordance with professional standards and applicable law. Client may request copies of records; Provider may charge a reasonable fee for copying and administrative costs, provided such fees comply with law.

GOVERNING LAW; DISPUTE RESOLUTION

This Agreement shall be governed by and construed in accordance with the laws of the State or jurisdiction indicated below. Governing Law:

The parties agree to attempt good faith negotiation to resolve disputes arising under this Agreement before initiating formal legal action. Where litigation is necessary, venue shall lie in the courts of the governing jurisdiction.

ENTIRE AGREEMENT; AMENDMENT; SEVERABILITY

This Agreement constitutes the entire agreement between the parties with respect to its subject matter and supersedes all prior agreements, understandings, and negotiations. Any modification or amendment must be made in writing and signed by both parties. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

ACKNOWLEDGMENT

By signing below, Client acknowledges that Client has read and understands this Agreement, has had the opportunity to ask questions, and consents to treatment under the terms described herein.

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