TREATMENT AGREEMENTTreatment Agreement • January 13th, 2017
If the patient has a high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician and patient outlining patient responsibilities, including:
TREATMENT AGREEMENT, CONSENT & ACKNOWLEDGEMENTTreatment Agreement • March 29th, 2023
First appointment: Your first visit will be with an admissions therapist who will provide a behavioral health assessment. At the end of this assessment, you and the therapist will discuss what services make sense.
TREATMENT AGREEMENT, CONSENT & ACKNOWLEDGEMENTTreatment Agreement • February 13th, 2020
First appointment: Your first visit will be with an admissions therapist who will provide a behavioral health assessment. At the end of this assessment, you and the therapist will discuss what services make sense. You will be assigned to a clinical provider who will be your clinical care coordinator. Your next
NANCY IREY HOLMES, PSY DTreatment Agreement • January 10th, 2020
TREATMENT AGREEMENTTreatment Agreement • January 13th, 2017
🞎 The physician should provide reasons for which drug therapy may be discontinued, such as violation of the treatment agreement.
Treatment AgreementTreatment Agreement • January 4th, 2023
I affirm that I have been offered a copy of the Behavioral Health Services (BHSI) Client Rights and Responsibilities document and am aware that I may request a copy at any time, or view or download it on the BHSI website at www.bhsiclinics.com.
The BHN RAAM Clinics Treatment AgreementTreatment Agreement • February 9th, 2022
TREATMENT AGREEMENT & CLIENT RIGHTSTreatment Agreement • July 7th, 2024
Welcome to my practice. This document (the Agreement) contains important informa- tion about my 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 client rights with re- gard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I pro- vide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which can be down- loaded from my website, explains HIPAA and its application to your personal health information in greater detail, and my practice is in general accordance with HIPAA policies. The law requires that I obtain your signature acknowledging that I have pro- vided you with this information by the end of the first session.
TREATMENT AGREEMENT & REFILL POLICYTreatment Agreement • December 23rd, 2023
As part of your treatment, our medical staff may prescribe medications for you. As you know, medications can have serious side effects if they are not managed properly. Your health and safety are very important to us, and we need your help to make sure your treatment follows the prescribed guidelines. No prescriptions will be written for you unless you accept the
Treatment AgreementTreatment Agreement • October 27th, 2021
This document is a brief orientation to my thinking about my psychiatric practice. After reading through it you may have questions for us. Please fax all the signed documents to 312.268.5085 or if you prefer you can email them as scanned attachment to asmajkic@pauboxmail.com . An understanding of these issues is very important. We have tried to spell out as clearly as possible how we think about these basic aspects of our practice.
TREATMENT AGREEMENT & ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESTreatment Agreement • March 31st, 2023
TREATMENT AGREEMENTTreatment Agreement • January 13th, 2017
🞎 The physician should provide reasons for which drug therapy may be discontinued, such as violation of the treatment agreement.
TREATMENT AGREEMENT FOR CHILDRENTreatment Agreement • December 10th, 2020
FEES: The fee per 50-minute session is $ (except for the first session, which is $ ). This is payable at the time of our session, unless I am billing your insurance (see below for insurance billing information).
Judith Mazza, Ph.D., PATreatment Agreement • May 24th, 2022
Appointments are scheduled by Dr. Mazza between Monday and Thursday. If you are calling regarding therapy for a couple or family, an initial two-hour session is recommended. Appointments for adult individuals are generally one hour in length.
ContractTreatment Agreement • August 1st, 2016
This form is provided for educational and informational purposes only. It is not intended to establish a legal or medical standard of care. Physicians should use their personal and professional judgment in interpreting this form and applying it to the particular circumstances of their individual patients and practice arrangements. The information provided in this form is provided “as is” with no guarantee as to its accuracy or completeness. ASAM will strive to update this form from time to time, but cannot ensure that the information provided herein is current at all times.
Treatment AgreementTreatment Agreement • July 22nd, 2024
FEES: The fee per individual 45-minute session is $225.00 due at the time of our session, unless I am billing your insurance, in which case you must pay your copayment and/or deductible at the session. Fees are the same for video, phone, or in-person sessions. CANCELLATION: Sessions are by appointment only. While I hate charging for missed sessions, I do reserve that time for you. Therefore, you will be charged the full session fee (not just a copayment) for missed sessions or for those canceled without 24-hour notice, except in medical emergencies. Insurance will not pay for missed sessions. Since your time is also valuable, if I forget a session, you get one session free. INSURANCE: I am a provider, and I will submit claims for you. In our session, you must pay any copayment or coinsurance for any portion not covered by your plan. There may be a deductible (an amount you will need to pay out of pocket) before your plan begins covering sessions. If insurance does not pay as expected,
Agreement to TreatmentTreatment Agreement • August 12th, 2021
Catalyst Therapeutic Services, PLLC offers psychiatry and psychotherapy services to children, adolescents, adults, and families.
TREATMENT AGREEMENTTreatment Agreement • June 25th, 2015
Welcome to Tandem Psychology, the private practice of Tyler Fortman, Ph.D. This document contains important information about Dr. Fortman’s professional services and business policies. Please read it carefully and ask questions as you need; it will assist you in making an informed decision about Dr.
Sample XR-NTX Treatment AgreementTreatment Agreement • September 14th, 2021
This form is for educational/informational purposes only. It doesn’t establish a legal or medical standard of care. Healthcare professionals should use their judgment in interpreting this form and applying it in the circumstances of their individual patients and practice arrangements. The information provided in this form is provided “as is” with no guarantee as to its accuracy or completeness.
Treatment AgreementTreatment Agreement • June 12th, 2020
These payment terms, including the conditions, policy lines, guidelines and instructions stated herein, (“Payment Terms”) and the general terms and conditions relating to your access to our services (“General Terms and Conditions”) form a legal contract between iMindU, Chamber of Commerce 67312969, having its registered office at Rapenburg 34A, 2311 EX LEIDEN, The Netherlands, and you, the patient and/or his/her legal representatives who has/have entered into a treatment relationship with us.
TREATMENT AGREEMENTTreatment Agreement • April 17th, 2024
INTAKE FORM: A signed intake demographic form along with copies of the front and back of all insurance cards are required and attests to the fact that you have received and agree to the following.
TREATMENT AGREEMENTTreatment Agreement • March 29th, 2024
Welcome to Lafene Health Center (LHC). This document contains important information about our services and business policies. Please read it carefully and note any questions you might have to discuss with your therapist/provider. When you sign this document, it will become an agreement between you, LHC and CAPS.
UAB Neurology and Pain Medicine Treatment Agreement & Refill PolicyTreatment Agreement • February 5th, 2018
As part of your treatment, you may be prescribed medications. As you know, medications can have serious side effects if they are not managed properly. Your health and safety are very important to us, and we need your help to make sure your treatment follow the prescribed guidelines.
Pier A. Talbot, LICSWTreatment Agreement • September 21st, 2021
FEES: The fee per 45-minute individual session is $130, 60-minute individual session $180, 45-minute couples/family session $140 and the first intake session $195. Full payment is due at the time of our session, unless I am billing your insurance, in which case your copayment and/or deductible is due at the session.
James M. Blue, Ph.D., Licensed PsychologistTreatment Agreement • April 12th, 2021
Welcome to the office of Dr. James M. Blue, a professional psychological services practice. The Treatment Agreement constitutes a formal agreement between us. Please read it carefully and raise any concerns that you have before you sign it. The Client Profile follows this agreement. The Client Profile includes a signature line stating that you understand the Therapy Agreement. Please complete and sign the Profile and return it to me prior to our first session.
TREATMENT AGREEMENT, CONSENT & ACKNOWLEDGEMENTTreatment Agreement • June 14th, 2024
First appointment: Your first visit will be with an admissions therapist who will provide a behavioral health assessment. At the end of this assessment, you and the therapist will discuss what services make sense. You will be assigned to a clinical provider who will be your clinical care coordinator. Your next appointment will be scheduled before you leave. You are welcome and encouraged to include friends and/or family at any point in your treatment process (with your written permission).
TREATMENT AGREEMENT, CONSENT & ACKNOWLEDGEMENTTreatment Agreement • June 7th, 2024
First appointment: Your first visit will be with an admissions therapist who will provide a behavioral health assessment. At the end of this assessment, you and the therapist will discuss what services make sense. You will be assigned to a clinical provider who will be your clinical care coordinator. Your next appointment will be scheduled before you leave. You are welcome and encouraged to include friends and/or family at any point in your treatment process (with your written permission).
ContractTreatment Agreement • September 30th, 2022
Treatment agreement HaptomotionTreatment Agreement • April 24th, 2024
Welcome to my haptotherapy practice, HaptoMotion. In order to inform you and en- sure a good collaboration, I have included several practical agreements in this treat- ment agreement that we will both sign.
TREATMENT AGREEMENTTreatment Agreement • January 13th, 2017
If the patient has a high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician and patient outlining patient responsibilities, including:
Treatment Agreement School Health CentersTreatment Agreement • August 30th, 2021
School Health Center services may include: *mental health services (treatment, assessment, individual, and family counseling);
TREATMENT AGREEMENT & ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESTreatment Agreement • September 13th, 2018
Treatment Agreement, Adherence, and Outcome in Cognitive Behavioral Treatments for InsomniaTreatment Agreement • September 4th, 2024
Background—Patient adherence has been identified as an important barrier to the implementation of evidence-based psychological treatments.
Agreement for Treatment with Buprenorphine/NaloxoneTreatment Agreement • October 15th, 2014
🞏 Yes 🞏 No I understand that buprenorphine/naloxone is a medication to treat opiate addiction (for example: heroin, prescription opiates such as oxycodone, hydrocodone, methadone). Buprenorphine/naloxone contains the opiate narcotic analgesic medication, buprenorphine, and the opiate antagonist drug, naloxone, in a 4 to1 (buprenorphine to naloxone) ratio. The naloxone is present in the tablet to prevent diversion to injected abuse of this medication. Injection of buprenorphine/naloxone by a person who is addicted to opiateswill produce severe opiate withdrawal. 🞏 Yes 🞏 No 1. I agree to keep appointments and let staff know if I will be unable to show up asscheduled 🞏 Yes 🞏 No 2. I agree to report my history and my symptoms honestly to my physician, nurses, and counselors involved in my care. I also agree to inform staff of all other physicians and dentists who I am seeing; of all prescription and non- prescription drugs I am taking; of any alcohol or street drugs I have recentlybe
TREATMENT AGREEMENTTreatment Agreement • January 13th, 2017
The physician should provide reasons for which drug therapy may be discontinued, such as violation of the treatment agreement.
