You can open the Therapeutic Separation Agreement Template in multiple formats, including PDF, Word, and Google Docs.
Therapeutic Separation Agreement Template Printable | Editable FormSample
[Name of the Therapist]
[Therapist’s ID]
[Therapist’s Practice Address]
[Therapist’s Phone]
[Therapist’s Email]
[Name of the Client]
[Client’s ID]
[Client’s Address]
This Therapeutic Separation Agreement is established to clarify the terms and conditions surrounding the therapeutic separation process, effective from [Contract Start Date].
The purpose of this agreement is to facilitate a structured and safe separation process for the Client, ensuring both parties are aligned on expectations.
The Therapist agrees to provide the following services: [Specify therapeutic services]. This may include counseling sessions, support resources, and therapeutic tools to aid in the separation process.
The Client agrees to pay the Therapist a fee of [Amount] per session, to be settled according to the following payment schedule: [Specify terms].
Therapeutic sessions will be held [Specify frequency and duration], with follow-up sessions planned as needed to monitor progress.
Either party may terminate this agreement under the following conditions: [Specify reasons for termination].
Both parties agree to maintain the confidentiality of all discussions and materials shared during therapeutic sessions.
The Client acknowledges that [Specify any limitations of liability for the Therapist].
[Signature of the Therapist]
[Name of the Therapist]
[Signature of the Client]
[Name of the Client]
[Name of the Therapist]
[Therapist’s ID]
[Therapist’s Practice Address]
[Therapist’s Phone]
[Therapist’s Email]
[Name of the Client]
[Client’s ID]
[Client’s Address]
This agreement is established to outline the framework and obligations regarding the therapeutic separation process, commencing on [Contract Start Date].
To ensure a collaborative and supportive path towards therapeutic separation, enhancing the Client’s emotional wellbeing.
The Therapist will provide: [List specific therapeutic services]. These services may include individual therapy sessions, group support, and relevant resources.
The Client agrees to compensate the Therapist with a fee of [Amount], payable upon [Specify payment terms].
Sessions will be evaluated at regular intervals to determine the effectiveness and adjust the therapeutic approach as necessary.
The agreement may be terminated based on mutual consent or if the separation goals have been achieved, or if circumstances deem it necessary: [Specify conditions].
Both parties agree to keep all information and discussions confidential, except as required by law.
The Client agrees to indemnify the Therapist against any claims arising from the services provided under this agreement.
[Signature of the Therapist]
[Name of the Therapist]
[Signature of the Client]
[Name of the Client]
Form
Please complete the form below to create the Therapeutic Separation Agreement Template. All fields must be filled out to ensure a clear and comprehensive agreement. We provide examples to guide you through each step. Therapeutic Separation Agreement Template 1. Participant Information 2. Therapist Information 3. Agreement Overview 4. Goals of Therapeutic Separation 5. Guidelines for Separation 6. Session Schedule 7. Confidentiality and Privacy 8. Re-evaluation Sessions 9. Termination Terms 10. Signatures and Acceptance 11. Declaration and Signatures
PDF
WORD
Therapeutic Separation Agreement Template Printable | Editable FormPrintable
