Common use of Other Points Clause in Contracts

Other Points. If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. These comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist, and you are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients. OUR AGREEMENT Please initial each statement and sign below. I understand I have the right not to sign this form. I have read and discussed this agreement. It does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the therapist, before I start formal therapy. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them. I understand that after therapy begins, I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy with you. I understand that no specific promises have been made to me by this therapist about the results of treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective. I have read, or had read to me, the issues and points in this document, discussed those points I did not understand, and have had my questions fully answered. I agree to act according to the points covered here. I agree to enter into therapy with this therapist, and to cooperate fully and to the best of my ability, as shown by my signature here. MY SIGNATURE BELOW INDICATES THAT I HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT I HAVE RECEIVED THE HIPAA NOTICE DESCRIBED ABOVE. Signature Date

Other Points. If you ever become involved in a divorce or custody dispute, I want you to understand and agree that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship and I must put this relationship first. If, as part of our therapy, you create and provide to me records, notes, artworks, or any other documents or materials, I will return the originals to you at your written request but will retain copies. If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. These Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist, therapist and you are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients. OUR AGREEMENT Please initial each statement and sign below. I I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have read and discussed this agreement. It ; it does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the therapist, before I start (or the client starts) formal therapy. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them. I understand that after therapy begins, begins I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy with you. I understand that no specific promises have been made to me by this therapist about the results of treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective. I have read, or have had read to me, the issues and points in this document, . I have discussed those points I did not understand, and have had my questions questions, if any, fully answered. I agree to act according to the points covered herein this brochure. I hereby agree to enter into therapy with this therapisttherapist (or to have the client enter therapy), and to cooperate fully and to the best of my ability, as shown by my signature here. MY Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. YOUR SIGNATURE BELOW INDICATES THAT I YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IT AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT I YOU HAVE RECEIVED THE HIPAA NOTICE DESCRIBED ABOVE. Signature DateSIGNATURE OF CLIENT DATE IF CLIENT IS A MINOR: CHILD’S NAME SIGNATURE OF PARENT #1 DATE PRINTED NAME SIGNATURE OF PARENT #2 DATE (REQUIRED IF PARENTS ARE SEPARATED OR DIVORCED AND HAVE JOINT LEGAL CUSTODY)

Other Points. If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. These comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist, and you are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients. OUR AGREEMENT Please initial each statement and sign below. I understand I have the right not to sign this form. I have read and discussed this agreement. It does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the therapist, before I start formal therapy. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them. I understand that after therapy begins, I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy with you. I understand that no specific promises have been made to me by this therapist about the results of treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective. I have read, or had read to me, the issues and points in this document, discussed those points I did not understand, and have had my questions fully answered. I agree to act according to the points covered here. I agree to enter into therapy with this therapist, and to cooperate fully and to the best of my ability, as shown by my signature here. MY SIGNATURE BELOW INDICATES THAT I HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT I HAVE RECEIVED THE HIPAA NOTICE DESCRIBED ABOVE. Signature Date

Other Points. If you are unhappy with what is happening ever become involved in therapya divorce or custody dispute, I hope you will talk with me so that I can respond to your concerns. These comments will be taken seriously and handled with care and respect. You may also request that I refer want you to another therapist, understand and you are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect agree that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have social a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first. 04.13.17 Patient Name: Medical Record Number: Xxxx-Xxxxx Xxxxxxx, M.D. Apex Child, Adolescent & Adult Psychiatry, p.A. Apex, North Carolina Our Agreement I, the client (or sexual relationships with clients his or with former clients. OUR AGREEMENT Please initial each statement and sign below. I her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have read and discussed received this agreement. It Agreement; it does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the therapistpsychiatrist, before I start formal therapy(or the client starts) formally working together and even after the work has begun. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them. I understand that after therapy begins, treatment begins I have the right to withdraw my consent to therapy treatment at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy treatment with you. I understand that no specific promises have been made to me by this therapist physician, about the results of treatment, the effectiveness of the procedures used by this therapistdoctor, or the number of sessions necessary for therapy treatment to be effective. I have read, will read, or have had read to me, the issues and points in this document, Agreement. I have discussed or will discuss those points I did not understand, and will have/have had my questions questions, if any, fully answered. I agree to act according to the points covered herein this Agreement. I hereby agree to enter into therapy work with this therapistpsychiatrist, and to cooperate fully and to the best of my ability, as shown by my signature here. MY SIGNATURE BELOW INDICATES THAT Signature of client (or person acting for client) Date Printed name Relationship to client Signature of physician Date I HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIPtruly appreciate the chance you have given me to be of professional service to you, and look forward to a successful relationship with you. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT If you are satisfied with my services as we proceed, I HAVE RECEIVED THE HIPAA NOTICE DESCRIBED ABOVE. Signature Date(like any professional) would appreciate your referring other people to me who might also be able to make use of my services.

Other Points. If you are unhappy with what is happening ever become involved in therapya divorce or custody dispute, I hope you will talk with me so that I can respond to your concerns. These comments will be taken seriously and handled with care and respect. You may also request that I refer want you to another therapist, understand and you are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect agree that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have social a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first. 04.13.17 Patient Name: Medical Record Number: XXXX-XXXXX XXXXXXX, M.D. APEX CHILD, ADOLESCENT & ADULT PSYCHIATRY, P.A. APEX, NORTH CAROLINA Our Agreement I, the client (or sexual relationships with clients his or with former clients. OUR AGREEMENT Please initial each statement and sign below. I her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have read and discussed received this agreement. It Agreement; it does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the therapistpsychiatrist, before I start formal therapy(or the client starts) formally working together and even after the work has begun. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them. I understand that after therapy begins, treatment begins I have the right to withdraw my consent to therapy treatment at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy treatment with you. I understand that no specific promises have been made to me by this therapist physician, about the results of treatment, the effectiveness of the procedures used by this therapistdoctor, or the number of sessions necessary for therapy treatment to be effective. I have read, will read, or have had read to me, the issues and points in this document, Agreement. I have discussed or will discuss those points I did not understand, and will have/have had my questions questions, if any, fully answered. I agree to act according to the points covered herein this Agreement. I hereby agree to enter into therapy work with this therapistpsychiatrist, and to cooperate fully and to the best of my ability, as shown by my signature here. MY SIGNATURE BELOW INDICATES THAT Signature of client (or person acting for client) Date Printed name Relationship to client Signature of physician Date I HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIPtruly appreciate the chance you have given me to be of professional service to you, and look forward to a successful relationship with you. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT If you are satisfied with my services as we proceed, I HAVE RECEIVED THE HIPAA NOTICE DESCRIBED ABOVE. Signature Date(like any professional) would appreciate your referring other people to me who might also be able to make use of my services.