Copy of Client Services Agreement/Rate Form

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) *

If other, please describe below.

The service(s) will be provided on the following day(s) *

If other, please state below

The rate of pay is * per session

If another rate arrangement were made, please specify below.

The service(s) will start on or about *

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. The signature date will be the same date as the one on the top of this electronic form. T *

Clear

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. Client/Representative signature in the box below.

Clear