External Consulting Contract

External Consulting Contract
Please indicate reason for consulting

Licensure pursposesOngoing Case Consultation
Name*

First NameLast Name
Phone Number*
Address*

Street Address

CityState / Province

Postal / Zip Code
Email*
example@example.com
Start Date*

MonthDayYear
Date
Agency
License can be uploaded here

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Please upload Proof of Liability Insurance Certificate here*

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Consultation Fee Based on a 50-Minute Session
$$
Consultant's Name

First NameLast Name
Consultation will include the following:
- Case consultation, with decision making authority on cases being held by the agency the supervisee comes from, including emergencies
- Discussion of Ethical concerns
- Therapist work
- Mutual evaluation and ongoing feedback
- Education as agreed upon
Consulting hours can be used for supervision hours for those seeking lisencesure. A 50 minute session session of consulting equals one hour of supervision.
Goals will be developed in a mutual process and may change over time
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Cancellations require 24-hour notice from the Consultee, with a fee for late cancellations or no shows, at the discretion of the Consultant. If the Consultant misses a session, the following session will be provided without charge.

We acknowledge by our individual signatures below, that each of us has read this Contract, that we understand it and have had an opportunity to discuss its content and that we enter Consultation in agreement with this Contract
Consultee Signature*

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