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Consultation Agreement
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Email *
Name *
What state are you located in? *
Have you contacted your license board about what specifications they require for clinicians to own and operate a private practice? (It is highly recommended, not required for our consultation services) *
What graduate school did you attend? *
What is your master's degree in? *
What year did you graduate? *
Licensed # *
Briefly explain what type of assistant you need to start your own private practice. *
What are your general ideas of the type of counseling practice you would like to start? Who is your ideal client? *
How long have you been in the counseling field? *
If I am eligible I would like to receive the 6 month promotional from Psychology Today. *
1. This agreement is for consultation and is not an agreement for counseling or a therapeutic treatment or services. This is a professional peer to peer consultation interaction. If I am in need of a therapist or counseling services I agree to seek an alternative resource within my local community. *
Required
2. Terms of Payment: The cost of each consultation session is 150. per session. Sessions last for 60 minutes. 30 min sessions are not offered. There is no refunds. Payments must be completed at least 24 hours prior to my session or my scheduled session will be canceled. *
Required
3. Forms of payment include credit cards. Samaria M Colbert does not take alternative forms of payment such as cashapp, cash or checks. If your credit card is declined, you will need to submit an alternative card at least 24 hour prior to your appointment or it will be canceled. *
4. Release and Waiver of Liability: I have voluntarily agreed to consultation with Samaria M Colbert. I hereby unconditionally release and forever discharge any persons, including Samaria M Colbert from any liabilities, damages, losses, expenses, claims or demands, from this consultation agreement. This document is a release of all liability, and contracts against Samaria M Colbert in court of law. I agree to a consultation professional interchange at my own free will. *
The consultation is NOT clinical supervision. If I am in need of a clinical supervisor I agree to find one with in my local area. *
5. It is the client's responsibility to keep up with their appointment. Meetings are to start on time, if the client is 15 minutes late or more to the appointment, the consultation session is canceled. There are no refunds issued.
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6. There is no audio or visual recording allowed in the consultation session. *
Consultations services are render via a virtual meeting *
Although we certainly understand that the nature of the consultation is to assist the clinician in starting there own private practice, it is ultimately the clinicians responsibility to start and build their own practice. We do not guarantee that upon completion of the consultation relationship you will have your own practice as the timing, process and procedure to completion is solely up to the potential clinician/business owner. *
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I have read the Terms and Conditions of the consultation agreement, and acknowledge that I am bound to the terms and conditions set forth in the agreement. I acknowledge that I am entering into the agreement voluntarily. If you agree type your full name below: *
Today's Date *
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What happens next? After the individual submits the necessary information. Your consultation is not approved yet. It will be sent to Dr. Samaria for review. If the consultation is not completed fully or there is some discrepancy it will be sent back to you. Your consultation will be either approved or denied. If approved your meeting request will be accepted, and an invoice will be emailed to you that must be paid at least 24 hours prior to your appointment. *
A copy of your responses will be emailed to the address you provided.
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