Common use of Termination of Therapy Clause in Contracts

Termination of Therapy. Therapist reserves the right to terminate therapy at her discretion, for reasons including but not limited to untimely fee payment, noncom- pliance with treatment recommendations, conflict of interest, failure to participate in therapy, or Patient needs being outside Therapist’s scope of practice or compe- tence. Patient also has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate, Therapist will usually recommend Patient par- ticipate in at least one termination session to facilitate a positive termination experi- ence and allow both parties to reflect on the work that has been done. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Patient. Acknowledgment: By signing below, Patient acknowledges that he/she has re- viewed and fully understands the terms and conditions of this Agreement. Patient has discussed the terms and conditions with Therapist, and any questions have been answered to Patient’s satisfaction. Patient agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. Patient Name (please print): Patient Signature: Date: Therapist Signature: Date: Xxxxxxx X. Xxxxxxx, XX, MA, LMFT xxxxxxxxxxxxxx.xxx CREDIT CARD AGREEMENT: Please Note: New clients are requested to keep a valid credit card number on file. Please complete the following information and provide your credit card to your clinician at your initial session. This is set up for your convenience. Credit Card Type: MasterCard Visa American Express Discover Name as shown on card: Credit Card Number: Expiration date: 3-digit security code on back of the card: If American Express, 4-digit code on front of the card: Billing Address associated with this credit/debit card: Email Address: This card may be charged for (Please initial all that apply): • Regular session fees (at your request, as a convenience to you): • Fees for same-day cancellation: • Fees for cancellation without 24-hour notice: • Delinquent session fees (fees more than 30 days overdue): • Document review (including emails, Court records, and correspondence) (charged in 10-minute increments): • Phone calls over ten minutes (with clients and collateral contacts) (charged in 10-minute increments): • I understand there are no refunds given: “I have read and understand the terms of provid- ing my credit card to Xxxxxxx X. Xxxxxxx, XX, MA, LMFT. I understand that my credit card may be charged for the reasons indicated above. I also understand there are no refunds given. Any questions I have about this practice have been answered and I xxxxxxxxxxxxxx.xxx give my full consent to charge my credit card under the circumstances checked above.” Your Signature Consenting to Charges: Today’s date:

Termination of Therapy. Therapist reserves the right to terminate therapy at her discretion, for reasons including but not limited to untimely fee payment, noncom- pliance with treatment recommendations, conflict of interest, failure to participate in therapy, or Patient needs being outside Therapist’s scope of practice or compe- tence. Patient also has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate, Therapist will usually recommend Patient par- ticipate in at least one termination session to facilitate a positive termination experi- ence and allow both parties to reflect on the work that has been done. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Patient. Acknowledgment: By signing below, Patient acknowledges that he/she has re- viewed and fully understands the terms and conditions of this Agreement. Patient has discussed the terms and conditions with Therapist, and any questions have been answered to Patient’s satisfaction. Patient agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. Patient Name (please print): Patient Signature: Date: Therapist Signature: Date: Xxxxxxx X. Xxxxxxx, XX, MA, LMFT xxxxxxxxxxxxxx.xxx CREDIT CARD AGREEMENT: Please Note: New clients are requested to keep a valid credit card number on file. Please complete the following information and provide your credit card to your clinician at your initial session. This is set up for your convenience. Credit Card Type: MasterCard Visa American Express Discover Name as shown on card: Credit Card Number: Expiration date: 3-digit security code on back of the card: If American Express, 4-digit code on front of the card: Billing Address associated with this credit/debit card: Email Address: This card may be charged for (Please initial all that apply): • Regular session fees (at your request, as a convenience to you): • Fees for same-day cancellation: • Fees for cancellation without 24-hour notice: • Delinquent session fees (fees more than 30 days overdue): • Document review (including emails, Court records, and correspondence) (charged in 10-minute increments): • Phone calls over ten minutes (with clients and collateral contacts) (charged in 10-minute increments): • I understand there are no refunds given: “I have read and understand the terms of provid- ing my credit card to Xxxxxxx X. Xxxxxxx, XX, MA, LMFT. I understand that my credit card may be charged for the reasons indicated above. I also understand there are no xxxxxxxxxxxxxx.xxx refunds given. Any questions I have about this practice have been answered and I xxxxxxxxxxxxxx.xxx give my full consent to charge my credit card under the circumstances checked above.” Your Signature Consenting to Charges: Today’s date:

Termination of Therapy. Therapist reserves the right to terminate therapy at her discretion, for reasons including but not limited to untimely fee payment, noncom- pliance with treatment recommendations, conflict of interest, failure to participate in therapy, or Patient needs being outside Therapist’s scope of practice or compe- tence. Patient also has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate, Therapist will usually recommend Patient par- ticipate in at least one termination session to facilitate a positive termination experi- ence and allow both parties to reflect on the work that has been done. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Patient. Acknowledgment: By signing below, Patient acknowledges that he/she has re- viewed and fully understands the terms and conditions of this Agreement. Patient has discussed the terms and conditions with Therapist, and any questions have been answered to Patient’s satisfaction. Patient agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. xxxxxxxxxxxxxx.xxx Patient Name (please print): Patient Signature: Date: Therapist Signature: Date: Xxxxxxx X. Xxxxxxx, XX, MA, LMFT xxxxxxxxxxxxxx.xxx CREDIT CARD AGREEMENT: Please Note: New clients are requested to keep a valid credit card number on file. Please complete the following information and provide your credit card to your clinician at your initial session. This is set up for your convenience. Credit Card Type: MasterCard Visa American Express Discover Name as shown on card: Credit Card Number: Expiration date: 3-digit security code on back of the card: If American Express, 4-digit code on front of the card: Billing Address associated with this credit/debit card: Email Address: This card may be charged for (Please initial all that apply): • Regular session fees (at your request, as a convenience to you): • Fees for same-day cancellation: • Fees for cancellation without 24-hour notice: • Delinquent session fees (fees more than 30 days overdue): • Document review (including emails, Court records, and correspondence) (charged in 10-minute increments): xxxxxxxxxxxxxx.xxx • Phone calls over ten minutes (with clients and collateral contacts) (charged in 10-minute increments): • I understand there are no refunds given: “I have read and understand the terms of provid- ing providing my credit card to Xxxxxxx X. Xxxxxxx, XX, MA, LMFT. I understand that my credit card may be charged for the reasons indicated above. I also understand there are no refunds given. Any questions I have about this practice have been answered and I xxxxxxxxxxxxxx.xxx give my full consent to charge my credit card under the circumstances checked above.” Your Signature Consenting to Charges: Today’s date:

Termination of Therapy. Therapist reserves the right to terminate therapy at his/her discretion. Reasons for termination include, for reasons including but are not limited to, untimely payment of fees, failure to untimely fee payment, noncom- pliance comply with treatment recommendations, conflict conflicts of interest, failure to participate in therapy, or Patient needs being are outside of Therapist’s scope of practice competence or compe- tencepractice, or Patient is not making adequate progress in therapy. Patient also has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminateterminate therapy, Therapist will usually generally recommend that Patient par- ticipate participate in at least one one, or possibly more, termination session sessions. These sessions are intended to facilitate a positive termination experi- ence experience and allow give both parties an opportunity to reflect on the work that has been done. Should patient request, Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Patient. Acknowledgment: Acknowledgement . (Please Initial) By signing below, Patient acknowledges that he/she has re- viewed reviewed and fully understands the terms and conditions of this Agreement. Patient has discussed the such terms and conditions with Therapist, and has had any questions have been with regard to its terms and conditions answered to Patient’s satisfaction. Patient agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. Moreover, Patient agrees to hold Therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment. I understand that I am financially responsible to Therapist for all charges. I understand that therapist accepts no form of insurance or any other third-party payments (Please initial). Signature of Patient (or authorized representative) Date Contact Information Patient Name (please print) Address City/State/Zip Phone Numbers Emergency Contact Date of Birth E-Mail Xxxxxxx X. Xxxxxx M.F.T. 000 Xxxxxx Xx, Xxxxx 000 Xxx Xxxxxxxxx, Xx. 00000 415 820-3943 Credit Card Authorization Form I, , am authorizing Xxxxxxx Xxxxxx M.F.T. to use my credit card information to charge my credit card for scheduled appointments and past due balances. I also authorize payment in the event that I do not notify him of my inability to attend a scheduled individual, couples or family therapy appointment and/or do not cancel my appointment at least 48 hours (business days) in advance as agreed to in the Financial Arrangement policies stated in the signed Client Agreement and Therapists Disclosures Form. I understand that there are no cancellations for group registration and that no credit or refunds for missed groups will be given. In case of late cancellations and/or no-shows for scheduled sessions, you will be charged the full session fee. Please complete the following information. This form will be securely stored in your clinical file and may be updated upon request at any time. Card Type (circle one): Patient SignatureVisa MasterCard Amex Other Card #: Expiration Date: Therapist Name as Printed on Card: Verification/Security Code (3-digit code on back by signature line) Billing Address: Street City State Zip Signature: Date: Xxxxxxx X. XxxxxxxXxxxxx M.F.T. 000 Xxxxxx Xx. Xxxxx 000 Xxx Xxxxxxxxx, XXXx. 00000 415.820.3943 Please provide contact information if you are currently receiving any other form of mental health care such as psychiatry, MAcouples counseling, LMFT xxxxxxxxxxxxxx.xxx CREDIT CARD AGREEMENT: Please Note: New clients are requested to keep a valid credit card number on filegroup therapy, medication management. Please complete the following information and provide your credit card to your clinician at your initial session. This is set up for your convenience. Credit Card Type: MasterCard Visa American Express Discover Name as shown on card: Credit Card Number: Expiration date: 3-digit security code on back of the card: If American ExpressI, 4-digit code on front of the card: Billing Address associated with this credit/debit card: Email Address: This card may be charged for (Please initial all that apply): • Regular session fees (at your request, as a convenience to you): • Fees for same-day cancellation: • Fees for cancellation without 24-hour notice: • Delinquent session fees (fees more than 30 days overdue): • Document review (including emails, Court records, and correspondencePatient Name) (charged in 10-minute increments): • Phone calls over ten minutes (with clients and collateral contacts) (charged in 10-minute increments): • I understand there are no refunds given: “I have read and understand the terms of provid- ing my credit card to hereby xxxxx Xxxxxxx X. Xxxxxxx, XX, MA, LMFT. I understand that my credit card may be charged Xxxxxx M.F.T. permission to release treatment information to: Provider’s Name Provider’s Phone number This authorization allows disclosure of information needed for the reasons indicated aboveabove mentioned purpose. I also understand there are no refunds givenIt shall be valid immediately and shall expire Date Signature Xxxxxxx X. Xxxxxx M.F.T. 000 Xxxxxx Xx Xxxxx 000 Xxx Xxxxxxxxx, Xx. Any questions I have about this practice have been answered and I xxxxxxxxxxxxxx.xxx give my full consent to charge my credit card under the circumstances checked above00000 415.820.3943 HIPAA NOTICE OF PRIVACY PRACTICES I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.” Your Signature Consenting to Charges: Today’s date:

Termination of Therapy. Therapist reserves the right to terminate therapy at her discretion, for reasons including but not limited to untimely fee payment, noncom- pliance with treatment recommendations, conflict of interest, failure to participate in therapy, or Patient needs being outside Therapist’s scope of practice or compe- tence. Patient also has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate, Therapist will usually recommend Patient par- ticipate in at least one termination session to facilitate a positive termination experi- ence and allow both parties to reflect on the work that has been done. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Patient. Acknowledgment: By signing below, Patient acknowledges that he/she has re- viewed and fully understands the terms and conditions of this Agreement. Patient has discussed the terms and conditions with Therapist, and any questions have been answered to Patient’s satisfaction. Patient agrees to abide by the terms and xxxxxxxxxxxxxx.xxx conditions of this Agreement and consents to participate in psychotherapy with Therapist. Patient Name (please print): Patient Signature: Date: Therapist Signature: Date: Xxxxxxx X. Xxxxxxx, XX, MA, LMFT xxxxxxxxxxxxxx.xxx CREDIT CARD AGREEMENT: Please Note: New clients are requested to keep a valid credit card number on file. Please complete the following information and provide your credit card to your clinician at your initial session. This is set up for your convenience. Credit Card Type: MasterCard Visa American Express Discover Name as shown on card: Credit Card Number: Expiration date: 3-digit security code on back of the card: If American Express, 4-digit code on front of the card: Billing Address associated with this credit/debit card: Email Address: This card may be charged for (Please initial all that apply): for: • Regular session fees (at your request, as a convenience to you): ) • Fees for same-day cancellation: cancellation • Fees for cancellation without 24-hour notice: notice • Delinquent session fees (fees more than 30 days overdue): ) xxxxxxxxxxxxxx.xxx • Document review (including emails, Court records, and correspondence) (charged in 10three-minute increments): ) • Phone calls over ten minutes (with clients and collateral contacts) (charged in 10three-minute increments): ) • I understand there are no refunds given: given “I have read and understand the terms of provid- ing providing my credit card to Xxxxxxx X. Xxxxxxx, XX, MA, LMFT. I understand that my credit card may be charged for the reasons indicated above. I also understand there are no refunds given. Any questions I have about this practice have been answered and I xxxxxxxxxxxxxx.xxx give my full consent to charge my credit card under the circumstances checked above.” Your Signature Consenting to Charges: Today’s date:

Termination of Therapy. Therapist reserves If necessary, I may terminate therapy if I determine that sessions are no longer in your best interest. Reasons for termination include, but are not limited to, repeated occurrences of late payments, an unwillingness to comply with agreed upon treatment recommendations, conflicts of interest, a resistance to participate in therapy, or psychological needs extend beyond my scope of competence or practice. You have the right to terminate therapy at her discretionyour discretion for these circumstances as well. If termination ensues, for reasons including but not limited to untimely fee payment, noncom- pliance with treatment recommendations, conflict of interest, failure to I will recommend that you participate in therapy, or Patient needs being outside Therapist’s scope of practice or compe- tence. Patient also has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate, Therapist will usually recommend Patient par- ticipate in at least one one, or possibly more termination session sessions. These sessions are intended to facilitate a positive termination experi- ence and allow both parties separation in order to provide an opportunity to reflect on the work that has been done. Therapist I will also attempt to ensure a smooth transition to another therapist by offering referrals qualified referrals. **Please continue to Patient. Acknowledgment: By signing below, Patient next page for signatures** Acknowledgement by Signatures My signature acknowledges that he/she has re- viewed I have reviewed and fully understands understand the terms and conditions of this Agreementagreement. Patient has discussed the I am aware I may discuss terms and conditions with Therapistmy therapist, and any questions have been answered to Patient’s satisfaction. Patient agrees I agree to abide by the terms and conditions of this Agreement agreement and consents I consent to participate in psychotherapy with Therapistpsychotherapy. My signature verifies that I hold Xxxxx Xxxxxxxx, Ph.D free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from our therapeutic work together. Patient Name (please print): ) Signature of Patient Signature: Date: Date I understand that I am financially responsible to Therapist Signature: Date: for all charges, including unpaid charges by any other third-party payor. Name of Responsible Party Date Signature of Responsible Party Date Xxxxx Xxxxxxxx, Ph.D MFT 85032 00000 Xxxxxxx X. Xxxxxx Xxxx # 000 Xxxxxxxx Xxxxxxx, XXXX 00000 (000) 000-0000 xxxxxxxxx@xxxxx.xxx Patient Information Referred by: Name of Patient: DOB Address: City State ZIP Home PH: ( ) - Cell: ( ) - Wk: ( ) - Email: Patient's Occupation: Patient's Workplace: Work Address: Spouse/Partner Name: Home PH: ( ) - Cell: ( ) - Wk: ( ) - Person responsible for payment (Please Print): DL# and State: Address (if different from above): City: State: ZIP: Other person(s) residing in Home (children, MAext. family members, LMFT xxxxxxxxxxxxxx.xxx CREDIT CARD AGREEMENTothers): Age: Relationship: _ Age: Relationship: Age: Relationship: Age: Relationship: Physician Name: Physician Phone: ( ) - Medication(s), dosage: Prescriber’s Name: Prescriber’s Phone: Prescriber’s Address: Emergency Contact (Please NotePrint Clearly): Emergency Phone : New clients are requested ( ) - Xxxxx Xxxxxxxx, Ph.D MFT 85032 00000 Xxxxxxx Xxxxxx Xxxx Xxxxx 000 Xxxxxxxx Xxxxxxx, XX 00000 (000) 000-0000 Xxxxxxxxx@xxxxx.xxx Authorization to keep Exchange Confidential Information I, [Name of Patient] authorize Xxxxx Xxxxxxxx, Ph.D to exchange confidential information regarding my treatment with [name and function of person to which information is to be exchanged] This Authorization permits the exchange of the following information: Any and All Information Necessary Diagnosis Progress to Date Patient Records Treatment Plan Prognosis Clinical Test Results Information limited to: This Authorization shall remain valid until: I understand that I have a right to receive a copy of this authorization. I also understand that any cancellation or modification of this authorization must be in writing (Patient or Patient’s Representative*) Date *If signed by other than Patient, please indicate the relationship between Patient and his/her Representative Credit Card Authorization Form I understand that this authorization is valid until canceled in writing. I understand this information is secured in a locked, protected patient file. I agree to assume the risk in the unlikely event this file and/or account is tampered with and credit card number on file. Please complete the following information and provide your credit card to your clinician at your initial session. This is set up for your convenience. Credit Card Type: MasterCard Visa American Express Discover Name as shown on card: Credit Card Number: Expiration date: 3-digit security code on back of the card: If American Express, 4-digit code on front of the card: Billing Address associated with this credit/debit card: Email Address: This card may be charged for (Please initial all that apply): • Regular session fees (at your request, as a convenience to you): • Fees for same-day cancellation: • Fees for cancellation without 24-hour notice: • Delinquent session fees (fees more than 30 days overdue): • Document review (including emails, Court records, and correspondence) (charged in 10-minute increments): • Phone calls over ten minutes (with clients and collateral contacts) (charged in 10-minute increments): • I understand there are no refunds given: “I have read and understand the terms of provid- ing my credit card to Xxxxxxx X. Xxxxxxx, XX, MA, LMFTcompromised. I understand that charges for missed sessions not cancelled within the agreed upon 24-hour cancellation period or non-payment at time of session will be posted to my credit/debit account within 48 hours of each session date and session fee will be charged on the day of my session. Additionally, I agree that the card listed below may be charged by my therapist in order to settle outstanding balances. I am responsible for charge back fees or retrieval fees. Initial I agree that if I have any concerns or questions regarding charges to my account, or if charge fails to post to my account, I will contact my therapist for assistance and/or disclosure. I agree that I will not dispute any charges with my credit card may be charged for the reasons indicated above. I also understand there are no refunds given. Any questions company unless I have about this practice already attempted to rectify the situation directly with my therapist and those attempts have been answered and I xxxxxxxxxxxxxx.xxx give my full consent to charge my credit card under the circumstances checked abovefailed.” Your Signature Consenting to Charges: Today’s date:

Termination of Therapy. Therapist reserves the right to terminate therapy at her discretion, for reasons including but not limited to untimely fee payment, noncom- pliance with treatment recommendations, conflict of interest, failure to participate in therapy, or Patient needs being outside Therapist’s scope of practice or compe- tence. Patient also has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate, Therapist will usually recommend Patient par- ticipate in at least one termination session to facilitate a positive termination experi- ence and allow both parties to reflect on the work that has been done. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Patient. Acknowledgment: By signing below, Patient acknowledges that he/she has re- viewed and fully understands the terms and conditions of this Agreement. Patient has discussed the terms and conditions with Therapist, and any questions have been answered to Patient’s satisfaction. Patient agrees to abide by the terms and xxxxxxxxxxxxxx.xxx conditions of this Agreement and consents to participate in psychotherapy with Therapist. Patient Name (please print): Patient Signature: Date: Therapist Signature: Date: Xxxxxxx X. Xxxxxxx, XX, MA, LMFT xxxxxxxxxxxxxx.xxx CREDIT CARD AGREEMENT: Please Note: New clients are requested to keep a valid credit card number on file. Please complete the following information and provide your credit card to your clinician at your initial session. This is set up for your convenience. Credit Card Type: MasterCard Visa American Express Discover Name as shown on card: Credit Card Number: Expiration date: 3-digit security code on back of the card: If American Express, 4-digit code on front of the card: Billing Address associated with this credit/debit card: Email Address: This card may be charged for (Please initial all that apply): • Regular session fees (at your request, as a convenience to you): • Fees for same-day cancellation: • Fees for cancellation without 24-hour notice: • Delinquent session fees (fees more than 30 days overdue): xxxxxxxxxxxxxx.xxx • Document review (including emails, Court records, and correspondence) (charged in 10three-minute increments): • Phone calls over ten minutes (with clients and collateral contacts) (charged in 10three-minute increments): • I understand there are no refunds given: “I have read and understand the terms of provid- ing providing my credit card to Xxxxxxx X. Xxxxxxx, XX, MA, LMFT. I understand that my credit card may be charged for the reasons indicated above. I also understand there are no refunds given. Any questions I have about this practice have been answered and I xxxxxxxxxxxxxx.xxx give my full consent to charge my credit card under the circumstances checked above.” Your Signature Consenting to Charges: Today’s date:

Termination of Therapy. Therapist reserves the right to terminate therapy at her discretion, for reasons including but not limited to untimely fee payment, noncom- pliance with treatment recommendations, conflict of interest, failure to participate in therapy, or Patient needs being outside Therapist’s scope of practice or compe- tencecompetence. Patient also has the right to terminate therapy at his/her discretion. Upon either partypar- ty’s decision to terminate, Therapist will usually recommend Patient par- ticipate participate in at least one termination session to facilitate a positive termination experi- ence experience and allow both parties to reflect on the work that has been done. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Patient. Acknowledgment: By signing below, Patient acknowledges that he/she has re- viewed and fully understands the terms and conditions of this Agreement. Patient has discussed the terms and conditions with Therapist, and any questions have been answered to Patient’s satisfaction. Patient agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. xxxxxxxxxxxxxx.xxx Patient Name (please print): Patient Signature: Date: Therapist Signature: Date: Xxxxxxx X. Xxxxxxx, XX, MAXX, LMFT xxxxxxxxxxxxxx.xxx CREDIT CARD AGREEMENT: Please Note: New clients are requested to keep a valid credit card number on file. Please complete the following information and provide your credit card to your clinician cli- nician at your initial session. This is set up for your convenience. Credit Card Type: MasterCard Visa American Express Discover Name as shown on card: Credit Card Number: Expiration date: 3-digit security code on back of the card: If American Express, 4-digit code on front of the card: Billing Address associated with this credit/debit card: Email Address: This card may be charged for (Please initial all that apply): for: • Regular session fees (at your request, as a convenience to you): ) • Fees for same-day cancellation: cancellation • Fees for cancellation without 24-hour notice: notice • Delinquent session fees (fees more than 30 days overdue): ) • Document review (including emails, Court records, and correspondence) (charged in 10three-minute increments): ) caitlinburgess.xm • Phone calls over ten minutes (with clients and collateral contacts) (charged in 10three-minute increments): ) • I understand there are no refunds givengiven Please enter the agreed upon fee between Therapist and Patient below: The agreed-upon fee is $ per 50-minute clinical hour. “I have read and understand the terms of provid- ing my credit card to Xxxxxxx X. Xxxxxxx, XX, MAXX, LMFT. I understand that my credit card may be charged for the reasons indicated above. I also understand there are no refunds given. Any questions I have about this practice have been answered and I xxxxxxxxxxxxxx.xxx give my full consent to charge my credit card under the circumstances checked above.” Your Signature Consenting to Charges: Today’s date:

Termination of Therapy. Therapist reserves the right to terminate therapy at his/her discretion. Reasons for termination include, for reasons including but are not limited to, untimely payment of fees, failure to untimely fee payment, noncom- pliance comply with treatment recommendations, conflict conflicts of interest, failure to participate in therapy, or Patient needs being are outside of Therapist’s scope of practice competence or compe- tencepractice, or Patient is not making adequate progress in therapy. Patient also or Representative has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminateterminate therapy, Therapist will usually generally recommend that Patient par- ticipate participate in at least one one, or possibly more, termination session sessions. These sessions are intended to facilitate a positive termination experi- ence experience and allow give both parties an opportunity to reflect on the work that has been done. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to PatientPatient or Representative. Acknowledgment: Acknowledgment By signing below, Patient Representative acknowledges that he/she has re- viewed reviewed and fully understands the terms and conditions of this Agreement. Patient Representative has discussed the such terms and conditions with Therapist, and has had any questions have been with regard to its terms and conditions answered to PatientRepresentative’s satisfaction. Patient Representative agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. Moreover, Representative agrees to hold Therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment. Patient Name (please print): ) Signature of Patient Signature: Date: Therapist Signature: Date: Xxxxxxx X. Xxxxxxx, XX, MA, LMFT xxxxxxxxxxxxxx.xxx CREDIT CARD AGREEMENT: Please Note: New clients are requested (if Patient is 12 or older) Date Signature of Representative (and relationship to keep a valid credit card number on file. Please complete the following information Patient) Date Signature of Representative (and provide your credit card relationship to your clinician at your initial session. This is set up for your convenience. Credit Card Type: MasterCard Visa American Express Discover Name as shown on card: Credit Card Number: Expiration date: 3-digit security code on back of the card: If American Express, 4-digit code on front of the card: Billing Address associated with this credit/debit card: Email Address: This card may be charged for (Please initial all that apply): • Regular session fees (at your request, as a convenience to you): • Fees for same-day cancellation: • Fees for cancellation without 24-hour notice: • Delinquent session fees (fees more than 30 days overdue): • Document review (including emails, Court records, and correspondencePatient) (charged in 10-minute increments): • Phone calls over ten minutes (with clients and collateral contacts) (charged in 10-minute increments): • I understand there are no refunds given: “I have read and understand the terms of provid- ing my credit card to Xxxxxxx X. Xxxxxxx, XX, MA, LMFT. Date I understand that I am financially responsible to Therapist for all charges, including unpaid charges by my credit card may be charged for the reasons indicated aboveinsurance company or any other third-party payor. I also understand there are no refunds given. Any questions I have about this practice have been answered Name of Responsible Party (Please print) Signature of Responsible Party (and I xxxxxxxxxxxxxx.xxx give my full consent relationship to charge my credit card under the circumstances checked above.” Your Signature Consenting to Charges: Today’s date:Patient) Date Name of Responsible Party (Please print)