Copy of Client Services Agreement/Rate Form
Services Agreement between the Client and Healingnotes.com/Shoshana Averbach (Provider) *indicates a required field
Name of Client
*
First Name
Last Name
Service Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Client
*
Please enter a valid phone number.
The service address is (choose 1)
*
the residence of the client
a temporary residence of the client
the home of a family member or friend where the client does not usually live
other (e.g., hospital, nursing home)
distance/proxy session (no service address)
Skpye/Zoom (no service address)
If other, please specify below and the location.
Name of Client Representative (if different from the client)
*
Phone Number of Client Representative (if different from the client)
*
Please enter a valid phone number.
Who is responsible for payment? (choose 1)
*
Client
Representative
Other
If the client representative or other is responsible for payment, please specify your relationship to the client
*
I am engaging Shoshana Averbach/Healingnotes.com for the following services (choose all that apply)
*
Music Therapy
Therapeutic/Assisted Activities
Energy & Spiritual Healing
Speaker/Presenter
Concert
Social Work Support Services/Case Management
Remote Spirit Release
Emotion Code/Body Code
Light Coaching
Music Lessons (indicate which instrument in the Other box below)
Other
If other, please describe below.
The service(s) will be provided as follows
*
To be determined
On an as-needed basis
Weekly
1-2x a month
Package of sessions to be used within 1 year
Other
If other, such as the number of sessions in a package, please state below
Date of initial session (on or about)
-
Month
-
Day
Year
Date
The rate of pay is
*
per session
If another rate arrangement were made such as a package price, please specify below. Packages must be used within 1 year from the date of purchase.
Other details if needed about the services
Payment method (choose 1)
*
cash
check (made out to "Shoshana Averbach")
PayPal (client pays any fees: Send to healingnotes@gmail.com.
Other
If other, please indicate below.
I, Shoshana Averbach, provider, have reviewed the terms above with the client or the representative.
*
Clear
Date of signature, Shoshana Averbach, provider
*
-
Month
-
Day
Year
Date
As the client or the client's representative, my signature below indicates that I agree to the Terms of Service on the healingnotes.com website, the information above regarding type(s) of services, day(s), and rate(s), and I will be responsible for full payment at the time of services. The name of the client appears at the beginning of the form.
*
Clear
Date of signature of client/representative
*
-
Month
-
Day
Year
Date
Submit
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