Professional Consent for Service Agreement

PROFESSIONAL CONSENT FOR SERVICE AGREEMENT

This Professional Consent for Service Agreement (the Agreement) is entered into as of between Professional: , License/ID: , with principal business address at (Professional), and Client: , with mailing address at (Client).

RECITALS

WHEREAS, Professional is duly qualified and licensed to provide the professional services described in this Agreement and represents that Professional maintains all qualifications, credentials and insurance required by applicable law to perform such services; and

WHEREAS, Client seeks and voluntarily consents to receive such professional services from Professional and acknowledges that Client has been informed of the nature, risks, anticipated benefits and alternatives to the services to be provided; and

WHEREAS, the parties desire to set forth the terms and conditions that will govern Professional's provision of services and Client's consent and obligations.

NOW, THEREFORE, in consideration of the mutual promises set forth herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. ENGAGEMENT AND CONSENT

1.1 Engagement. Professional agrees to provide and Client consents to receive the professional services described in Section 2 (the Services). Professional shall perform the Services in accordance with generally accepted professional standards and applicable law.

1.2 Informed Consent. Client acknowledges receipt of sufficient information regarding the nature, purpose, expected benefits and material risks of the Services to make an informed decision. Client hereby gives informed consent to the Services specified in this Agreement and authorizes Professional to provide such Services consistent with this Agreement and applicable standards.

2. SCOPE OF SERVICES

2.1 Description. The scope of Services will include the following general description; specific objectives, methods and limitations are set forth below and may be supplemented by written service plans:

2.2 Changes. Any material change to the Services shall be in writing and signed by both parties and shall specify any change in fees or schedule.

3. PROFESSIONAL DUTIES AND STANDARDS

3.1 Standard of Care. Professional shall exercise the degree of skill, care and diligence ordinarily exercised by members of the same profession in good standing practicing under similar circumstances. Professional does not guarantee specific results.

3.2 Subcontracting. Professional may engage qualified agents or subcontractors to perform portions of the Services but remains responsible for the performance of such agents and subcontractors under this Agreement.

3.3 Recordings and Observations. Client authorizes the following: Recording for clinical or training purposes? (check to consent)

4. CLIENT REPRESENTATIONS AND CONSENTS

4.1 Capacity. Client represents and warrants that Client is of sound mind and has the legal capacity to consent to the Services. If Client is not the decision-maker, Client represents that the signer has authority to consent on behalf of the person receiving Services.

4.2 Disclosure. Client will promptly disclose to Professional all information relevant to the provision of Services including current medications, prior relevant history and any restrictions that may affect treatment.

5. CONFIDENTIALITY AND RECORDS

5.1 Confidentiality. Except as authorized by Client or permitted by law, Professional will maintain the confidentiality of Client records and communications. Disclosures required by law (including mandatory reporting obligations) are not considered a breach of confidentiality.

6. FEES, BILLING AND PAYMENT

6.1 Fees. Client agrees to pay fees for Services at the rates set forth below. Payment is due as invoiced unless otherwise agreed in writing.

7. TERM AND TERMINATION

7.1 Term. This Agreement begins on the Effective Date and shall continue until the completion of the Services or until earlier terminated in accordance with this Section.

7.2 Termination for Cause. Either party may terminate this Agreement for material breach by the other party upon written notice if the breach is not cured within thirty (30) days after written notice. Termination shall not relieve Client of the obligation to pay for Services performed through the effective date of termination.

8. LIABILITY AND INDEMNITY

8.1 Limitation of Liability. Except to the extent prohibited by applicable law, Professional's total liability arising out of or related to this Agreement shall not exceed the amount of fees paid by Client to Professional under this Agreement or , whichever is greater.

8.2 Indemnity. Client shall indemnify and hold harmless Professional from and against any third-party claims, losses or liabilities arising from Client's breach of this Agreement or Client's negligence, except to the extent resulting from Professional's gross negligence or willful misconduct.

9. INSURANCE

10. NOTICES

All notices, consents or communications required or permitted under this Agreement shall be in writing and delivered to the addresses set forth below or to such other address as either party may designate by written notice to the other.

11. AMENDMENTS

This Agreement may only be amended by a written instrument signed by both parties. Any purported amendment that is not in writing and signed by both parties shall be void.

12. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to its conflict of law principles.

13. ENTIRE AGREEMENT

This Agreement, including any attachments or written service plans expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations and understandings, whether oral or written.

14. SEVERABILITY

If any provision of this Agreement is held to be invalid, illegal or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect and shall be construed to effectuate the parties' intent to the fullest extent permitted by law.

15. WAIVER

No waiver of any breach of this Agreement shall constitute a waiver of any other or subsequent breach. No waiver shall be valid unless in writing and signed by the party granting the waiver.

16. COUNTERPARTS

This Agreement may be executed in counterparts, each of which shall be an original, and all of which together shall constitute one and the same instrument. Signatures transmitted by electronic means shall be deemed original signatures for the purposes of this Agreement.

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