New Growth Psychotherapy llc Joy LanzanoTherapy Services Agreement • March 4th, 2022
This agreement is intended to provide you, the client, with important information regarding the practices, policies, and procedures of Joy Lanzano, the therapist, and to clarify the terms of the professional therapeutic relationship between client and therapist. Any questions or concerns with the contents of this agreement should be discussed prior to signing.
AGREEMENT FORMTherapy Services Agreement • September 28th, 2010
As an informed consumer, it is important that you understand the terms and conditions of any services that you receive. The following document describes the terms and conditions of services provided by Dr. Bob Dick and your rights and responsibilities as a client. Please discuss this form with Dr. Dick prior to signing it.
AGREEMENTTherapy Services Agreement • March 30th, 2022 • Ohio
WHEREAS, SCHOOL desires the services of licensed therapists for its students – specifically: speech, behavioral, physical and occupational therapists and/or assistants, as further described below (collectively, “Therapy Services”);
Neuropsychology & Concussion Management Associates, LLC (NCMA) Therapy Services Agreement and Consent FormTherapy Services Agreement • April 27th, 2023
This document contains information about our professional services and business policies. It also provides information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides certain privacy protections and patient rights regarding the use and disclosure of your Protected Health Information. HIPAA requires that we provide you with a Notice of Privacy Practices; this is available to you at www.NCMAmaine.com and in our waiting room and from our office staff. We will mail it to you on request. In order to provide services to you, we require your signature acknowledging that we have provided you with access to this information and that you have given your informed consent to the services and the practices described in this document. When you sign this document, it will represent an Agreement between us. You may cancel this Agreement in writing at any time. That cancellation will be binding except 1) to the extent that we have already taken action
Agreement & ConsentTherapy Services Agreement • April 17th, 2023
• If for any reason you are unable to make your session, cancellation notice is 48 hours, from the time of your appointment, otherwise the full fee is charged.
Therapy Services AgreementTherapy Services Agreement • December 11th, 2023
Welcome to Moxie Incorporated, Center for Life Health, Ltd. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient
New Growth Psychotherapy llc Joy LanzanoTherapy Services Agreement • April 10th, 2024
This agreement is intended to provide you, the client, with important information regarding the practices, policies, and procedures of Joy Lanzano, the therapist, and to clarify the terms of the professional therapeutic relationship between client and therapist. Any questions or concerns with the contents of this agreement should be discussed prior to signing.
AGREEMENTTherapy Services Agreement • April 21st, 2021 • Ohio
THIS AGREEMENT made on this 21st th day of April 2021, in Fairlawn, Ohio, by and between LLA THERAPY LLC (“LLA”) and NORTON CITY SCHOOLS, (“SCHOOL”).
AGREEMENT FOR THERAPY SERVICES Welcome to the therapeutic practice of Leyla Safavi, MFA, MA, LMFT. This document contains important information about my professional services and business policies. It also contains information about my policies and...Therapy Services Agreement • March 31st, 2019
Psychotherapy is not easily described in general statements. It varies depending on the personality of both the therapist and the patient and the particular problems that the patient brings. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit; it calls for an active effort on the part of the patient. Psychotherapy can aid you in discovering tools and techniques that can be utilized to improve the quality of your life and your relationships. Psychotherapy involves change, which may feel threatening not only to you but also to those people close to you. The prospect of giving up old habits, no matter how destructive or painful, can often make you feel very vulnerable. The process can include experiencing feelings like sadness, guilt, anxiety, anger, and fear and making changes that you did not originally intend. Like any professional service, therapy may not work, and for a relatively small number
WALK TALK THERAPY SERVICES AGREEMENT NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATIONTherapy Services Agreement • March 13th, 2019
This document contains important information about my professional services and business policies. It also contains information about my policies and practices to protect the privacy of your health information. Please read it carefully and discuss any questions you may have with me. When you sign this document, you will be stating that I provided you with this information and it will represent an agreement between us.
THERAPY SERVICES AGREEMENTS (2024-2025)Therapy Services Agreement • October 8th, 2024 • Utah
This Therapy Services Agreement (“Agreement”) is made effective as of August 14th, 2024 (“Effective Date”) between Utah Virtual Academy (“UTVA” or “School”), with its principal place of business at 4500 South 310 East Suite 620, Murray, Utah 84107, and
THE BRIDGE FAMILY CENTER AGREEMENT FOR THERAPY SERVICESTherapy Services Agreement • September 14th, 2016
AGREEMENT FOR THERAPY SERVICESTherapy Services Agreement • September 27th, 2019
NVision You’s mission is to equip adolescents to older adults with how to achieve a more rewarding life in their relationships, career, and mind-body health by helping clients identify and live in their highest values and confidently face uncomfortable experiences that may arise.
CONTRACT FOR THERAPY SERVICESTherapy Services Agreement • August 13th, 2014
This agreement is made and entered into August 21, 2014 by and between Leona Wing, Teacher for Visually Impaired Students, certified in the state of Kentucky, and Carroll County Schools.
ContractTherapy Services Agreement • October 1st, 2014 • Florida
This therapy services agreement, known as “agreement”, is made and entered into this day of , 20 , by and between Affordable Rehab Services Inc., hereinafter known as "Company" and hereinafter known as "Contractor". Whereas, the parties desire to enter into this agreement in accordance with the following terms and conditions. Therefore, in consideration of the mutual promises and covenants set forth in this agreement, the parties agree as follows: CONTRACTOR: 1 Agrees to provide therapy services to those patients designated by company in accordance with the treatment plan established by the patient's attending physician and in accordance with the applicable standard of care of reasonably prudent similar therapists. 2 Shall abide by all the applicable rules regulations and standards set forth in the federal laws, laws of the state of Florida, agencies, and organizational and professional associations to which the contractor may belong. Nothing in this agreement shall be construed to int
EAMHC has a contractual agreement to provide school based individual, family, and group therapy to Auburn City Schools students as identified by Auburn City Schools administration.Therapy Services Agreement • September 9th, 2019
If the school your child attends feels your child may be in need of therapy services they will contact you (the parent/guardian). If you are in agreement for these services, the school administration will complete a re- ferral form and obtain a release of information. This referral form will be sent to Family and Children’s
AGREEMENT OF THERAPY SERVICESTherapy Services Agreement • January 5th, 2016
This Agreement provides you with information that is additional to that detailed in the Notice of Privacy Practices (HIPAA).
Policies and Agreement for Therapy ServicesTherapy Services Agreement • May 28th, 2020
All information disclosed in our sessions and the written records of those sessions are confidential and may not be revealed to anyone without your informed consent, except where the law requires disclosure. Disclosure is required by law when there is a reasonable suspicion of child, dependent or elder abuse or neglect and when a client presents a danger to self, to others, to property or is gravely disabled. In addition, disclosure may be required in a legal proceeding. These policies are in keeping with the Personal Information Protection Electronic Documents Act 2004 (PIPEDA) and the Personal Health Information Protection Act 2004 (PHIPA).
THERAPY SERVICES AGREEMENTTherapy Services Agreement • June 12th, 2022 • Virginia
This Therapy Services Agreement (“Agreement”) is made effective as of March 20, 2022 (“Effective Date”) between K12 Virtual Schools LLC (“K12”), a Delaware limited liability company, with its principal place of business at 2300 Corporate Park Drive, Herndon, VA 20171 and PROVIDER (“Provider”), a(n) Georgia Limited Liability Company (LLC) having a principal place of business at 123 Future Way, , Anywhere, USA 12345 (each is a “Party,” and collectively, the “Parties”). Capitalized terms shall have the meaning set forth herein or in the applicable Addendum incorporated into this Agreement.
THERAPY SERVICES AGREEMENT BETWEENTherapy Services Agreement • April 5th, 2021 • Wisconsin
This THERAPY SERVICES AGREEMENT is entered into by and between Upland Hills Health, Inc. (hereinafter “Hospital”) and the River Valley School District Board of Education (hereinafter “School”).
AGREEMENT FOR THERAPY SERVICESTherapy Services Agreement • October 27th, 2022
Welcome to the therapeutic practice of Susan Lessley, MA, LMFT. This document contains important information about my professional services and business policies. It also contains information about my policies and practices to protect the privacy of your health information. Please read this document carefully and let me know if you have any questions or concerns. By signing this document, you will be stating that you were provided with this information and it will represent a binding agreement between us.
THERAPY SERVICES AGREEMENTTherapy Services Agreement • October 14th, 2020
If you need to cancel because of illness or another pressing commitment, please call the front desk staff at the scheduled office you are seen at as soon as possible.
Therapy Services Agreement for Child/AdolescentTherapy Services Agreement • November 13th, 2021
Client Information Child/Adolescent’s Name: Date of Birth (yyyy-mon-dd): Full Address: Parent/Guardian Name(s): Relationship: Parent/Guardian(s) Phone Number: Is it okay to leave a message? Parent/Guardian(s) E-mail: Is it okay to communicate through e-mail? (please note, confidentiality cannot be guaranteed via e- mail) Confidentiality All communication regarding treatment and all records relating to the provision of therapy services are confidential and will not be disclosed without written consent. Confidentiality cannot be guaranteed over e- mail communication. The law does however; place limits on confidentiality related to specific disclosures.These include:1. Risk of imminent danger to self or others2. Abuse of child or a vulnerable adult3. Court ordersWorking with a child includes the difficult task of protecting the child’s right to privacy while at the same time respecting the parent/guardian’s desire for information. Therapy is most effective when
ContractTherapy Services Agreement • January 2nd, 2020
ContractTherapy Services Agreement • October 17th, 2021
Welcome to Balance Stress Management & Therapy! Following is some essential information about your treatment with (therapist)
Therapy Services Agreement AdultTherapy Services Agreement • June 6th, 2022
Client Information Client’s Name: Date of Birth (yyyy-mon-dd): Full Address: Phone Number: Is it okay to leave a message? E-mail: Is it okay to communicate through e-mail? (pleasenote, confidentiality cannot be guaranteed via e- mail) Confidentiality All communication regarding treatment and all records relating to the provision of therapy services are confidential and will not be disclosed without written consent. The law does however; place limits on confidentiality related to specific disclosures. These include:1. Risk of imminent danger to self or other2. Abuse of child or a vulnerable adult3. Court ordersIf you disclose involvement in illegal activities, I reserve the right to take action based on the informationprovided and my discretion. This may include sharing the information with relevant bodies such as the police. Informed Consent Examples of problems you may be experiencing that may benefit from accessing services at Willow Therapy include abuse, add
AGREEMENT FOR SERVICE / INFORMED CONSENTTherapy Services Agreement • September 19th, 2022
This Agreement is intended to provide important information regarding the practices, polices, and procedures of Lisa Chen (herein “The therapist”), and to clarify the terms of the professional therapeutic relationship between the therapist and the client. Any questions or concerns regarding the contents of this Agreement should be discussed with the therapist prior to signing it.
HIS AGREEMENT executed on this the ______ day of , 20__ but agreed to be effective fromTherapy Services Agreement • August 25th, 2009
WHEREAS, Therapist represents that she has received training in Applied Behavioral Analysis (“ABA”). WHEREAS, Parents need an independent contractor to provide ABA therapy to their child _.
CONTRACT FOR THERAPY SERVICESTherapy Services Agreement • November 11th, 2011
In consideration of the mutual promises, agreements, and undertakings hereinafter set forth, it is hereby agreed as follows:
AGREEMENT FOR THERAPY SERVICESTherapy Services Agreement • May 15th, 2021
NVision You’s mission is to equip its clients with the tools and insights to achieve a more rewarding life in their relationships, career, and mind-body health by helping clients identify and live in their highest values and confidently face uncomfortable experiences that may arise.
THERAPY SERVICES AGREEMENT CONSENTTherapy Services Agreement • January 9th, 2013
This form is used to acknowledge and confirm your understanding and agreement of the services. Your signature below indicates your approval.
WALK TALK THERAPY SERVICES AGREEMENT NOTICE OF POLICIES AND PRACTICES TOTherapy Services Agreement • September 23rd, 2013
This document contains important information about our professional services and business policies. It also contains information about our policies and practices to protect the privacy of your health information. Please read it carefully and discuss any questions you may have with me. When you sign this document, you will be stating that I provided you with this information and it will represent an agreement between us.
Therapy Services Agreement 2021-22Therapy Services Agreement • August 17th, 2021 • Idaho
Term of agreement and Termination: This agreement shall remain in effect for a period of one (1) year and may be terminated by either party at any time, with or without cause, by delivery of no less than 30 days advance written notice of termination.
ADDENDUM TO THERAPY SERVICES AGREEMENTTherapy Services Agreement • June 12th, 2022
This addendum (“Addendum”) to the Therapy Services Agreement (“Agreement”) between K12 Virtual Schools L.L.C. (“K12”) and [PROVIDER NAME] (“Provider”) with an effective date of [EFFECTIVE DATE] shall become effective on the date that it bears the signature of both Parties.
EXHIBIT 10.44Therapy Services Agreement • March 31st, 1997 • Centennial Healthcare Corp • Tennessee
