Service Agreement Form

Complete via our secure web-form below or download, complete and return to us.

Service Agreement

Step 1 of 15

Welcome

Welcome to Abundance of Hope! This form provides information about services offered. Please review it carefully and feel free to contact me with any questions. We are happy to assist you.

About my Services

Therapy has many potential benefits and may include improved personal and professional growth, stress management, relationships, grief, self-image, and mood. Clients will learn the importance of how to foster growth, heal, the difference between unhealthy vs healthy coping skills, effective communication, and work to create behavioral changes. Change can be difficult and there will be some discomfort which will be apart of the therapeutic process. Clients will collaborate with the therapist to address and navigate through any difficult and or painful memories. We will work as a team to create a holistic approach through evidence base practices to address your therapeutic goals

Scheduling & Cancellation & Late Arrival

Scheduling an appointment is a commitment that both the therapist and client honor. There is a 15-minute grace period to arrive to the scheduled therapy session or it will be documented as a No Show which you will be responsible for the payment. All therapy sessions are scheduled by appointment. If you need to reschedule your appointment, please contact the office 24 hours prior to your appointment. If sessions are canceled or rescheduled with less than the required notice, or if a client misses a session, the client agrees to pay for the missed appointment. This fee is expected within 7 business days prior to your next session held. Please know that exceptions to this policy may be made in the event of a serious medical or family emergency

Work Agreement

It is agreed that the client shall engage in the therapeutic process as a priority in her/his life. Suspension, termination, or referral shall be discussed between therapist and client for a pattern of behavior displaying disinterest, lack of communication, or for any unresolved conflict or impasse between therapist and client. Clients agree they will not hold me (Anna Maith, LGPC), nor my practice (Abundance of Hope, LLC), accountable in any way for possible injury.

Emergency Contact

The client will provide at least two emergency contacts, such as, the phone number and address of a family member, partner, or close friend. These emergency contacts may be used if I am unable to reach you and I perceive a need. I will also obtain alternative methods for contacting you, such as, cell and or work phone number. If you are in crisis and cannot reach me, please contact emergency services (911) or go to the nearest emergency room.

Service Fees

Anna Maith, Abundance of Hope, LLC is a Board Approved Licensed Graduate Professional Counselor by the State of Maryland. The charge for the first session

We, the therapist and client, have read and fully understand and agree to honor this agreement. We have also agreed to an initial definition of work and to the fee to be paid by the client.

Client Name

Provider Name

Intake Date

Demographic Information

Client Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone (mobile)

Phone (work)

Phone (home)

Social Security#

Date of Birth

Age

Gender

Male

Female

Race/Ethnicity:

Presenting Difficulties/ Challenges:

Current Medication (s):

Please place one medication per line. Leave blank if none

Allergies:

Please place one allergy per line. Leave blank if none

Full Name of Guardian/ Spouse:

First Last

Phone (mobile)

Phone (work)

Phone (home)

Person responsible for payment:

First Last

Social Security #

Signature of Person Responsible for Payment(Required)

Emergency Information

In case of an emergency, contact:

Name

Relationship

Phone (mobile)

Phone (work)

Phone (home)

Address

Street Address Address Line 2 City State ZIP Code

Add another contact

yes

Name

Relationship

Phone (work)

Phone (home)

Phone (mobile)

Address

Street Address Address Line 2 City State ZIP Code

Do you want to continue on to the Informed Consent Form?(Required)

Yes

Questions / Concerns

Use the form to contact us with your questions and concerns. We will have someone contact you as soon as possible.

You can also use the information below to contact us.

Thank You

Email

Info@abundanceofhopellc.com

Phone

443.242.4098