Fill and Sign the Psychotherapy Form

Agreement for Psychotherapy Services Agreement made on the ________________ (date), between __________________ (Name of Therapist) of _______________________________________________________ _________________________ (street address, city, state, zip code) , referred to herein as Therapist , and __________________ (Name of Patient), of __________________________ _______________________________________________________ (street address, city, state, zip code) , referred to herein as Patient. For and in consideration of the mutual covenants contained in this agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: 1. Fees and Insurance Patient is responsible to pay $________ per 1/4 hour of psychotherapy services. Full payment shall be made by the Patient at the end of each session. Patient agrees to pay for professional services even if such services are covered by insurance. If services are covered by insurance Patient is responsible for requesting reimbursement directly from the insurance provider. 2. Policy regarding Cancellation and Failure to make Appointment Patient agrees to maintain responsible relations regarding appointment times. When Patient agrees to an appointment date time he/she is agreeing to pay for that time and will be charged for the time in the event of a no-show. In the event that Patient realizes that he/she is unable to make the scheduled appointment, please call Therapist at ________________ (phone number) to notify him of the cancellation. If the appointment is canceled 24 hours in advance of the appointed time Patient will not be charged. 3. Confidentiality Policy All therapeutic communications, records, and contact with professional and support staff will be held in strictest confidence. Information may be released, in accordance with state and federal law, only when A. The patient signs a written release of information indicating informed consent to such release; B. The patient expresses serious intent to harm himself/herself or someone else; C. There is evidence or reasonable suspicion of abuse against a minor child, elderly person or dependent adult; or D. A subpoena or other court order is received directing the disclosure of information. It is the policy of Therapist to assert (a) privileged communication in the event of Subsection D or (b) the right to consult with the patient, if at all possible baring an emergency, before mandated disclosure in the event of Subsections B or C. Although Therapist cannot guarantee it, he will endeavor to apprise Patient of all mandated disclosures. Patients with any concerns or questions about this policy agree to raise them with Therapist at the earliest possible time to resolve them in the patients’ best interest. 4. Work Agreement A. It is agreed that the Patient shall make a good-faith effort at change and personal growth, and engage in the psychotherapy process as an important priority at this time in his or her life. Patient gain is most important in the psychotherapy relationship. B. Patient requests that the following needs or problem issues will be addressed in both psychotherapy sessions and in Patient’s homework, with future revisions possible as need arises; please check all that apply  Marriage Relationship  Parent / Child Relationship  Addiction  Depression  Personal Direction  Spiritual Growth  Anxiety  Loneliness  Blended Family  Divorce Recovery  Grief and Loss  Family Violence  Relationship Counseling  Premarital Counseling  Family of Origin  Trauma / Abuse Recovery  Disordered Eating Pattern  Child Behavioral Problem 5. Informed Consent and Full Release of Liability A. Patient acknowledges that he/she is 18 years of age or older. Patient hereby agree to ASSUME ALL RISKS of personal injury, sickness, death, damage and expense arising from or related to Patient’s participation in the Therapy with Therapist. Patient hereby releases and discharges Therapist and agrees to protect, defend and hold Therapist harmless from and against any and all claims, demands, causes of action of every kind and character, losses, costs, expenses (including attorney fees) and damages of every kind and character for injury, sickness or death and any damage or alleged damage to any property sustained or alleged to have been sustained arising out of, or related to or incident to, my participation in the therapy with Therapist , regardless of whether such claims, demands, causes of action of every kind and character, losses, costs, expenses (including attorney fees) and damages are caused by the negligence of Therapist. B. Patient hereby gives permission for Therapist to secure needed medical treatment in the event that Patient is unable to give such permission. Therapist does not have any obligation to provide medical assistance. Patient hereby agrees to indemnify, defend and hold Therapist harmless for any liability, loss, cost or expense sustained as the result of the acts or omissions of Patient. C. Before Patient participates in therapy with Therapist, Patient agrees to inform Therapist of any medical condition, restriction or other condition Patient has which could, or could have the potential to, cause Patient or others harm by Patient’s participation in therapy with Therapist. 6. Severability The invalidity of any portion of this Agreement will not and shall not be deemed to affect the validity of any other provision. If any provision of this Agreement is held to be invalid, the parties agree that the remaining provisions shall be deemed to be in full force and effect as if they had been executed by both parties subsequent to the expungement of the invalid provision. 7. No WaiverThe failure of either party to this Agreement to insist upon the performance of any of the terms and conditions of this Agreement, or the waiver of any breach of any of the terms and conditions of this Agreement, shall not be construed as subsequently waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred. 8. Governing Law This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of _____________. 9. Notices Unless provided herein to the contrary, any notice provided for or concerning this Agreement shall be in writing and shall be deemed sufficiently given when sent by certified or registered mail if sent to the respective address of each party as set forth at the beginning of this Agreement. 10. Attorney’s Fees In the event that any lawsuit is filed in relation to this Agreement, the unsuccessful party in the action shall pay to the successful party, in addition to all the sums that either party may be called on to pay, a reasonable sum for the successful party's attorney fees. 11. Mandatory Arbitration Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect. 12. Entire Agreement This Agreement shall constitute the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this Agreement. 13. Modification of Agreement Any modification of this Agreement or additional obligation assumed by either party in connection with this Agreement shall be binding only if placed in writing and signed by each party or an authorized representative of each party. 14. Assignment of Rights The rights of each party under this Agreement are personal to that party and may not be assigned or transferred to any other person, firm, corporation, or other entity without the prior, express, and written consent of the other party. 15. Confidentiality Contractor and Employer both acknowledge that all information and materials furnished from the Employer Broker concerning this Agreement and the performance of it is confidential and may not be used for any purpose other than in connection with this Agreement. 16. Counterparts This Agreement may be executed in any number of counterparts, each of which shall be deemed to be an original, but all of which together shall constitute but one and the same instrument. 17. Compliance with Laws In performing under this Agreement, all applicable governmental laws, regulations, orders, and other rules of duly-constituted authority will be followed and complied with in all respects by both parties. 18. In this Agreement, any reference to a party includes that party's heirs, executors, administrators, successors and assigns, singular includes plural and masculine includes feminine. WITNESS our signatures as of the day and date first above stated. ________________________ _________________________ (Printed Name of Patient) (Printed Name of Therapist) _________________________ _________________________ (Signature of Patient) (Signature of Therapist)