Therapy Services Waiver

Therapy Services Waiver

RECITALS

WHEREAS, Provider Name: holds qualifications and licensure to provide mental health and behavioral health services and agrees to render such services to Client; and

WHEREAS, Client Name: voluntarily seeks therapy services and understands the nature, risks, and expected benefits of those services; and

WHEREAS, the parties desire to set forth the terms governing the provision of therapy, payment, risks, confidentiality limits, and the allocation of responsibilities between them.

SCOPE OF SERVICES

Provider will deliver psychotherapy, counseling, and related behavioral health services as described below. Services may include individual therapy, couples therapy, group therapy, assessment, treatment planning, case management, and referral services as appropriate.

PAYMENT TERMS

Session Fee: $ per session. Client is responsible for fees not covered by insurance and for obtaining any necessary referrals or authorizations.

Cancellation: Appointments canceled with less than notice may be subject to a cancellation fee equal to the full session fee, unless otherwise excused by Provider.

TERM AND TERMINATION

This Agreement Commences on: and continues until: , unless earlier terminated by either party.

Either party may terminate services with written notice given at least prior to the intended termination date. Provider may terminate immediately for client nonpayment or conduct that endangers staff or other clients.

CONFIDENTIALITY AND LIMITS

All communications between Client and Provider are confidential and will not be disclosed except as permitted by law. Exceptions include: (a) a reasonable suspicion of child, dependent adult, or elder abuse or neglect; (b) expressed intent to harm self or others; (c) information subject to a valid court order; (d) when Client consents in writing to disclosure; or (e) when required for collection of unpaid fees. Provider may share information with supervisors or legal counsel as necessary, provided identifying information is minimized when possible.

ASSUMPTION OF RISK AND WAIVER

Client acknowledges that psychotherapy involves discussing emotions, memories, and past events which may result in emotional discomfort. Client accepts these risks and releases Provider from liability for indirect or unforeseeable consequences arising from therapy, except to the extent of gross negligence or willful misconduct. This waiver does not limit any rights that cannot be waived by law.

I acknowledge and agree: (check box to indicate understanding and acceptance)

TELEHEALTH CONSENT

Telehealth (remote) services may be offered using audio or video. Client understands telehealth has limitations (e.g., technical failure, privacy risks) and consents to receive services remotely when appropriate.

Consent to Telehealth: (check to consent)

CLIENT INFORMATION

Client is a minor: If checked, Parent/Guardian Name:

GOVERNING LAW

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

ENTIRE AGREEMENT

This document constitutes the entire agreement between Client and Provider regarding therapy services and supersedes all prior agreements, understandings, and communications, whether written or oral. Any amendments must be made in writing and signed by both parties.

Certification: By signing below, Client and Provider certify that they have read and understand this Waiver, that Client consents to the services described herein, and that no representations, promises, or inducements have been made other than those contained in this Agreement.

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