• Educational Advocacy Form

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  • I, give consent to discuss health related information about my child, with teachers and counselors.

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  • THIS CONSULTING AGREEMENT (this “Agreement”) is made and  entered on  (Today's Date) by and among Teal Dragon Healing, LLC  (“Consultant”) and  (“Client”).  

    WHEREAS, Consultant, via its sole member, founder and CEO Adena Blickstein (“Owner”) has considerable knowledge and expertise in the  adult, child and adolescent psychiatry field, and Owner is licensed to  practice adult, child and adolescent psychiatry under the laws of the  State of New York; and  

    WHEREAS, Client desires to have Consultant perform certain services  for Client subject to the terms and conditions hereinafter provided;  

    NOW, THEREFORE, in consideration of the foregoing premises, and  the terms, covenants, and conditions set forth in this Agreement, and for  other good and valuable consideration, the parties hereby agree as  follows:  

    1. Performance of Consulting Services. Consultant agrees to provide  consulting services to Client in connection with Client’s family member  as more specifically detailed on attached Schedule A (the “Services”).  

    2. Not Medical or Professional. It is a condition of this Agreement that it  be understood and agreed, AND IT HEREBY IS UNDERSTOOD AND  AGREED, (i) that the Services shall be consulting in nature, and shall  not include any medical, clinical or professional services to Client or  Client’s family member and (ii) that the Services are not a substitute for  emergency or crisis services, if any, that are clinically indicated or  recommended under the circumstances. Further, Client acknowledges  and agrees that all medical, clinical and professional decisions and other  decisions with respect to patient care shall be under the sole discretion  and control of Client and such licensed professionals of Client’s  choosing, to the exclusion of Consultant. Notwithstanding the foregoing, Dr. Adena Blickstein may provide certain clinical services separate and  apart from this Agreement. 

    3. Compensation; Expenses.  

    (a) Upon Client’s execution of this Agreement, Client shall remit to  Consultant the minimum fee of $3,500 (“Minimum Fee”) which shall be  credited against the first 5.5 hours of Service. The Minimum Fee shall  be deemed earned by Consultant upon Client’s execution of this  Agreement and shall not be refundable to Client under any  circumstances.  

    (b) For Consultant’s Services rendered beyond 5.5 hours, Client agrees  to pay Consultant at the rate of $625 per hour. Such additional hours  may be billed in one-quarter hour increments.  

    (c) Consultant shall also be reimbursed by Client for all necessary and  reasonable expenses incurred by it in the performance of the Services  hereunder.  

    (d) Invoices indicating the time spent on the Services and expenses  incurred will be sent by Consultant to Client periodically. Payment by  Client of such invoices is due on receipt.  

    (e) Consultant has made no representation regarding the maximum fees  will be charged for the Services  

    4. Terms The term of the consulting arrangement shall commence on the  date that this Agreement is signed by Client and shall be in effect until  terminated by Consultant or Client upon written notice to the other.  Consultant may terminate this Agreement at any time upon completion  of the first 5.5 hours of Service for any or no reason. Client may  terminate this Agreement at any time for any or no reason. Upon a  termination of this Agreement, Consultant shall deliver a final invoice to  Client setting forth all hours of Service rendered through the date of  termination, and payment shall be made by Client immediately upon  receipt thereof.  

    5. Consent; Cooperation. In order to facilitate the Services, Client agrees  to direct (or cause family member to direct) all professional providers  providing services to Client’s family member to communicate and share 

    information with Consultant with respect to the professional services  provided by each such provider to Client’s family member by signing a  HIPAA release or other required form. Further, Client agrees to take  such other actions as are reasonably requested by Consultant in order to  facilitate the Services.  

    6. No Guaranty. Client acknowledges and agrees that there is no promise  or guaranty made by Consultant that any specific result can or will be  achieved. Consultant’s Services are consulting in nature only.  

    7. Release. This Agreement is contingent on Client, on behalf of itself  and its family members, releasing Consultant from all liability, and  Consultant would not enter into this Agreement but for the following  release:  

    In consideration of the terms of this Agreement, the receipt and  sufficiency of which are hereby acknowledged, Client hereby acting of  his/her own free will and on behalf of him/herself, the family member  and each of his/her other family members and each of their heirs,  executors, administrators, successors, and assigns (each as “Releasor”),  knowingly and voluntarily DOES HEREBY FULLY AND  GENERALLY RELEASE AND DISCHARGE CONSULTANT AND  OWNER, and each of its and their heirs, executors, administrators,  successors and assigns (each, as “Releasee”) from any and all actions,  causes of action, suits, debts, dues, sums of money, accounts,  reckonings, bonds, bills, specialties, covenants, contracts, controversies,  agreements, promises, variances, trespasses, damages, judgments,  extents, executions, claims, and demands whatsoever, in law, admiralty  or equity which against a Releasee a Releasor ever had, now has or  hereafter can, shall or may have, regardless of whether such claims are  known or unknown or discovered or not yet discovered, including, but  not limited to, any and all claim(s) arising from (i) Consultant’s  performance of the Services hereunder; (ii) suicide or attempted suicide  by Client’s family member; (iii) bodily harm or other injury caused by  Client’s family member to him/herself or to others; (iv) criminal activity  of Client’s family member; (v) medication side effects; (vi) clinical  treatment or hospitalization of Client’s family member; (vii) failure by 

    Client to accept or adhere to clinical treatment protocols or  recommendations; (viii) failure to seek or receive emergency or crisis  treatment or to admit Client’s family member for hospitalization where  appropriate; (ix) or otherwise, in each case whether arising under any  public policy, contract, constitutional, common law, or tort theory  (including, but not limited to, claims for medical, professional or other  malpractice, negligence, negligent or intentional infliction of emotional  distress, defamation, assault, battery, false imprisonment, invasion of  privacy, or any type of claim), whether based on statute, contract,  common law or otherwise. However, this general release of claims  excludes any claims which cannot be waived by law.  

    8. Choice of Law. This Agreement shall be governed by, and construed  in accordance with, the laws of the State of New York without regard to  conflicts of laws principles.  

    9. Notices. Any notice, request, consent or communication under this  Agreement shall be effective only if it is in writing and (i) personally  delivered or emailed, (ii) sent by certified mail, return receipt requested,  postage prepaid, or (iii) sent by a nationally recognized overnight  delivery service, with delivery confirmed, to the addresses set forth  above. All notices shall be effective upon delivery or refusal. Either  party may change its address by notice to the other.  

    10. Miscellaneous.  

     . (a) Entire Agreement. This Agreement constitutes the entire  agreement among the parties hereto pertaining to the subject matter  hereof and supersedes all prior agreements and understandings  pertaining thereto.  

     . (b) Amendment. This Agreement may be altered, waived,  amended or revoked at any time, or from time to time by an  instrument in writing duly executed by both parties. 

     . (c) Non-Waiver. The failure of a party at any time to require  performance of the other party of any provision hereof or to resort  to its remedy at law or in equity or otherwise, shall in no way  affect the right of such party to require such full performance or to  resort to such remedy at any time thereafter, nor shall the waiver  by any party of a breach of any provision hereof be taken or held to  be a waiver of any subsequent breach of such provision unless  expressly so stated in writing. No waiver of any of the provisions  hereof shall be effective unless in writing and signed  

    by the party to be charged with such waiver.  

     . (d) Partial Invalidity. If any of the provisions, terms or conditions  of this Agreement is  

    held to be invalid or unenforceable, then the remaining provisions,  terms and conditions which can be affected without such invalid or  unenforceable part of the Agreement shall nonetheless remain in  full force and effect.  

     . (e) Counterparts. This Agreement may be executed in counterparts  and each counterpart shall be considered as an original. One  counterpart shall be delivered to each of the parties hereto. This  Agreement shall be effective immediately upon its execution by  both parties.  

     . (f) Headings. The caption headings in this Agreement are solely  for convenience or reference and shall not affect its interpretation.  

    IN WITNESS WHEREOF, the parties have executed this Agreement  effective as of the day and year first above written.  

    SCHEDULE A “Services”  

    Consultant shall provide the following Services, NONE OF WHICH  SHALL BE MEDICAL, CLINICAL OR PROFESSIONAL IN  NATURE:  

     . (a) General consulting services (meet and confer with Client,  advise Client);  

     . (b) Prepare action plan;  

     . (c) Suggest and mobilize required professional services for family  member;  

     . (d) Arrange appointments with desired professional providers;  

     . (e) Communicate with professional providers on Client and family  member’s behalf;  

     . (f) Advocate for family member’s mental and educational needs;  and  

     . (g) Such other services as are agreed upon by Consultant and  Client. 

     

     

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