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1. Parties: Identification of the therapist/practice and client, including full legal names and contact details
2. Background: Brief context explaining the purpose of the form and the therapeutic relationship
3. Definitions: Key terms used throughout the document defined for clarity
4. Nature of Services: Description of the therapy services being provided and their intended purpose
5. Informed Consent: Client's acknowledgment of understanding the nature, benefits, and risks of therapy
6. Confidentiality: Explanation of privacy policies and limits to confidentiality
7. Client Rights and Responsibilities: Outline of what the client can expect and what is expected of them
8. Emergency Procedures: Protocol for crisis situations and emergency contacts
9. Fee Structure: Clear outline of fees, payment terms, and cancellation policy
10. Release of Liability: Client's acknowledgment of inherent risks and waiver of certain legal rights
11. Termination: Circumstances and procedures for ending the therapeutic relationship
12. Execution: Signature block for all parties, including date and witness if required
1. Telehealth Services: Additional terms specific to online therapy sessions, used when offering remote services
2. Group Therapy Provisions: Special conditions for group therapy participation, included when offering group sessions
3. Recording Consent: Terms for recording sessions, included when sessions may be recorded for training or supervision
4. Insurance and Medicare: Terms related to health insurance claims and Medicare benefits, included when accepting insurance
5. Research Participation: Terms for using anonymized data for research, included when conducting research
6. Minor Client Provisions: Additional terms when treating minors, including parental consent requirements
7. Cultural Considerations: Specific provisions for culturally sensitive therapy, included when relevant to the practice
1. Schedule A - Privacy Policy: Detailed privacy policy and information handling procedures
2. Schedule B - Fee Schedule: Comprehensive breakdown of all possible fees and payment terms
3. Schedule C - Cancellation Policy: Detailed terms regarding cancellations, rescheduling, and associated fees
4. Schedule D - Emergency Contact Form: Client's emergency contact information and authorization
5. Appendix 1 - Specific Therapy Techniques: Description of specific therapeutic methods that may be used
6. Appendix 2 - Client Rights Charter: Detailed explanation of client rights in therapy
Practitioner
Client
Treatment
Informed Consent
Confidential Information
Health Information
Personal Information
Emergency Contact
Practice
Session
Treatment Plan
Professional Standards
Clinical Records
Medicare Benefits
Telehealth Services
Force Majeure
Privacy Policy
Cancellation Policy
Business Day
Fee Schedule
Medical Emergency
Private Health Information
Therapeutic Relationship
Clinical Notes
Guardian
Duty of Care
Mental Health Care Plan
Professional Indemnity Insurance
Referral Source
Confidentiality
Privacy
Service Description
Fee Payment
Liability
Termination
Emergency Procedures
Record Keeping
Insurance
Cancellation
Communication
Professional Boundaries
Risk Disclosure
Client Rights
Practitioner Obligations
Dispute Resolution
Force Majeure
Assignment
Amendments
Governing Law
Severability
Entire Agreement
Electronic Communications
Health and Safety
Healthcare
Mental Health Services
Allied Health
Psychology
Counseling
Social Services
Medical Practices
Rehabilitation Services
Alternative Medicine
Occupational Health
Legal
Compliance
Clinical Operations
Administrative
Risk Management
Patient Services
Quality Assurance
Professional Standards
Healthcare Services
Document Management
Psychologist
Counselor
Occupational Therapist
Physical Therapist
Speech Therapist
Mental Health Practitioner
Clinical Social Worker
Practice Manager
Healthcare Administrator
Legal Compliance Officer
Risk Management Officer
Clinical Director
Therapy Services Coordinator
Allied Health Professional
Clinical Supervisor
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