TERMS OF AGREEMENT

TERMS OF AGREEMENT
Date (mm/dd/yyyy):
Client(s):
House Calls specialist completing form:
Please review and add/edit add if desired:

Education

Check

Comment

Accommodation

Advocacy

Organization

Coaching

Funding

Assessment

Other:

Job/Career

Check

Comment

Searches

Role Plays

Coaching

Interpersonal

Organization

Dependability Issues

Assessment

Skill Building

Funding for Job Sustainability

Other:

Transport

Check

Comment

Metro Access

Senior Cab Service

Travel Training

Other:

Life Transition

Check

Comment

Assisted Living

Respite Care

Day Program

Independent Living

Home Care

Providing Support

Searching for Families

Other:

Advocacy

Check

Comment

Help Navigate Mental Health System

Help navigate medical system

Baby Boomer Issues

Dealing with difficult professionals. Please Explain: Going with client, advocating, writing reports on their behalf

Medication Issues

Doctor Issues

Residential Issues

Financial Issues

Housing Issues

School System

Family Issues

Daily Living

Check

Comment

Money Management

Organization

Hoarding

De-Cluttering

Social/Recreation

Community Integration

Vocational

Educational

Social Restoration and Friendships

Check

Comment

Identifying Interests

Assessments

Other:

Obtaining Resources

Check

Comment

Social Security

Medicaid

Housing

Funding

Transportation

Doctors

Legal Help

Counseling/Medical

Check

Comment

Recovery Coaching

Grief and/or Trauma

Crisis Referral

Anxiety and/or Depression

Psychiatrist

General Counseling

Telehealth/Skype Appointments

Educational

Client's Providers:

House Calls will reserve this professional for one week while you review this agreement. The agreement document must be signed and returned to House Calls within this 5 day period.

Contractor

Contractor: Will be reserved based on services requested

Service: Outlined

Hourly Fee: $150

Travel Fee: $25 or IRS

House Calls Comments

Billing

Person Responsible for bill is:
Name:
Street Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Work Phone:
Email:
example@example.com
Indicate preferred payment option:

I prefer to pay for services when they are received. I prefer to be invoiced monthly and pay by check or through credit card (Paypal).
*Any invoice over $500 I will provide my credit card to be charged automatically.
Name on Credit Card:
Credit Card (Visa, Mastercard, American Express):
Credit Card Number:
Expiration Date (mm/yyyy)
Security Code:
Credit Card Signature

Clear
If I select monthly billing, I understand that payment must be received before the start of the next billing cycle or a $50 late fee will be incurred each service period until payment is paid in full. If I negotiate to be billed monthly, I understand that payment is expected 15 days after receipt of invoice by check or credit card through the paypal button on House Calls, LLC homepage.
Terms of Agreement Memorandum

A standard travel fee of $25 is charged for local travel within Montgomery County
Travel exceeding the Montgomery County radius will be based on current IRS rates per mile.

Agree
Initial

Clear
Any phone calls, emails, referrals, and/or advocacy work after the initial consultation, will be billed at an hourly rate same as above We will give you advance notice if this is necessary.

Agree
The action plan for services agreed will be emailed to select member(s) of the House Calls team working with this client and one client representative (if not the client).

Agree
Additional fees may apply if House Calls is asked to create multiple action plans, perform any other service and/or discuss the action plan with more than one client representative.

Agree
Name of Person Paying Bill
Agree to pay House Calls, LLC immediately for all services rendered.

Agree *NOTE: I understand if cancelling an appointment or if I do not show up for an appointment in less than 24 hours of appointment, I will be billed the original fee.
Other Expenses: I also understand that any court costs, collections, administrative work or other related expenses incurred in attempting to collect fees will be the responsibility of the party responsible for paying the bill.

Agree
Permission given to House Calls, LLC: Permission is given to House LLC to communicate with other parties relevant to the client's rehabilitation goals and objectives. At all times confidentiality will be respected unless there is imminent harm, bodily injury or abuse which requires our team to seek help. We are not a crisis service and defer to family or community resources to take action.

Agree
No Guarantees: Client, referring party and payee (if different from client or referring party) understand that House Calls LLC does not guarantee any specific results for Client. House Calls, LLC operates as an interdisciplinary team and the client is expected to be involved in his/her progress at all times.

Agree
Email Privacy Statement For Your Information: In general, email communications are not secure. Please check here for your informed consent to communicate through these channels. If you do not check this, we will assume you will print this Intake (or download the pdf Intake Form to bring with you). I am aware of the risks associated with sending House Calls emails or other channels. I give my consent for email correspondence.

Agree
Name of person responsible for paying the bill (Print name):

Signature/Electronic Signature of person responsible for paying
Name of Person responsible for paying the bill (Print Name):
Signature/Electronic Signature of person responsible for payingthe bill: *This signature is binding as if handwritten *

Clear
Date (mm/dd/yyyy):
I hereby agree to be bound by this agreement and am aware that this electronic signature is enforceable as if it were handwritten. This verifies that I give my written consent to bill me for any of the above related expenditures including legal fees, court costs and collection expenses involved for breach of contract.
*This agreement is effective as of the date it is signed by the client or client's authorized representative. To the extent permitted by law, House Calls cannot be held responsible for the performance of contractors or of House Calls overall. This indemnification and hold harmless agreement shall be made effective as of the date that this terms of agreement is agreed upon by all parties wherein the client requests services from House Calls LLC, its agents and/or contractors to the maximum extent permitted by law indemnitor will indemnify, defend and hold harmless House Calls LLC, agents and/or contractors from any and all claims, actions, liabilities, lawsuits, injuries, demands, obligations, losses, settlements, time spent, judgments, penalties, costs and expenses including attorney fees and collectively all claims and all types of damages out of or relating to any act or omission by the indemnitor in connection with the performance of House Calls LLC, agents and/or contractors activities and overall performance. Any claim brought forward related to this indemnity agreement which would cause House Calls LLC agents and/or contractors to incur these costs described is the responsibility of client and/or indemnitee. *

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TERMS OF AGREEMENT

Client's Providers:

Billing

Terms of Agreement Memorandum