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[ FORM 29 —Use the top of this page for your letterhead.] Agreement to Pay for Professional Services I request that the therapist named below provide professional services to me or to , who is my , and I agree to pay this therapist’s fee of $ per session for these services. I agree that this financial relationship with this therapist will continue as long as the therapist provides services or until I inform him or her, in person or by certified mail, that I wish to end it. I agree to meet with this therapist at least once before stopping therapy. I agree to pay for services provided to me (or this client) up until the time I end the relation- ship. I agree that I am responsible for the charges for services provided by this therapist to me (or this client), although other persons or insurance companies may make payments on my (or this client’s) account. I have also read this therapist’s “Information for Clients” brochure and agree to act according to everything stated
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Unformatted text preview: there, as shown by my signature below and on the brochure. Signature of client (or person acting for client) Date Printed name I, the therapist, have discussed the issues above with the client (and/or the person acting for the client). My obser-vations of the person’s behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. Signature of therapist Date q Copy accepted by client q Copy kept by therapist FORM 29. Agreement to pay for professional services. From The Paper Office . Copyright 2008 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details)....
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