Treatment Agreement

 

This Treatment Agreement____________________ is entered into on _____________, between:

 

Client Information:

 

• Full Name of Client: _____________________________

• Date of Birth: _________________

• Address: ______________________________________

• Phone Number: ______________________

 

PMHNP Information

 

• Name of Provider: _______________________________

• Credentials: ______________________

• Practice Name (if applicable): _______________________

• Contact Information: ___________________________________

 

Purpose of Agreement:

This Agreement outlines the terms and conditions governing the therapeutic relationship between the client and the provider, including the goals, expectations, and responsibilities of both parties.

 

Scope of Services:

The provider agrees to provide mental health assessment and medication management services to the client. The client agrees to actively participate in the therapeutic process.

 

Confidentiality:

The provider agrees to maintain confidentiality, with exceptions as required by law or in situations where there is a risk of harm to the client or others. The client understands and acknowledges these limitations of confidentiality.

 

Sessions:

 

• Assessment or treatment will be conducted at the agreed-upon frequency and duration.

• The client agrees to attend scheduled appointment punctually. If unable to attend, the client will provide absence notice for cancellations or rescheduling.

 

Fees and Payments:

 

• Fees for mental health evaluation and treatment are $250 for initial psych. $150 for follow up appointment and medication management/refill.

• Payment is due at the time of each visit or as otherwise agreed upon.

• The provider reserves the right to adjust fees with reasonable notice.

 

 

 

 

Insurance:

 

• If the client is utilizing insurance, they are responsible for providing accurate information and understanding their coverage.

• The client is responsible for any fees not covered by insurance.

 

Termination of Services:

Either party may terminate service with reasonable notice. The provider reserves the right to terminate services if continuation is deemed inappropriate or ineffective.

 

Collaboration and Communication:

The client agrees to openly communicate with the provider regarding their progress, concerns, or changes in circumstances that may impact treatment.

 

Emergency Contact:

The client will provide an emergency contact person and their contact information.

 

Agreement Review and Amendments:

This Agreement may be reviewed and amended as needed. Any amendments will be discussed and agreed upon by both parties.

 

 

Signature:

Client: ________________________

Date: _______________

 

PMHNP (provider): ______________________

Date: _______________

 

 

Note: It is advisable to seek legal advice when creating a Treatment Agreement to ensure compliance with applicable laws and ethical standards.

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Download PDF Version here.