Services Contract

Client Information:

Client Name(Required)

Address(Required)

Phone Number

Email

Indicated Client Information:

Primary Concerns/Issues:

Services Required (as identified in intake)

Preferred Method of Communication:

Emergency Contact Name

Emergency Contact Phone Number

Relevant Medical Information (if any)

Overdose Risk (if applicable)

Emergency Support Referral Sources for Families:

Local Crisis Hotline

National Suicide Prevention Lifeline: 1-800-273-TALK (8255)

SAMHSA National Helpline: 1-800-662-HELP (4357)

Local Support Groups

Addiction Recovery Resources

Link to Look Up 30-Day Residential Treatment Programs: Find Treatment

Link to Emergency Services: Locate Emergency Services

Narcan Availability (if applicable):

Narcan (naloxone) is available at many pharmacies without a prescription.

Local pharmacies where Narcan can be obtained:

Pharmacy Name

Untitled

Phone Number

When to Seek Immediate ER Services:

Clients or family members should seek immediate emergency room (ER) services if the client:

Shows signs of a drug overdose, such as difficulty breathing, unresponsiveness, or severe confusion.
Exhibits suicidal thoughts or behaviors or expresses a plan to harm themselves.
Experiences severe withdrawal symptoms, such as seizures, hallucinations, or extreme agitation.
Engages in behaviors that pose an immediate danger to themselves or others.
Experiences a medical emergency related to substance use or a co-occurring mental health disorder.

Services Selected:

Service Type:

Service

Package/Service Details:

Service

Total

Services Selected:

Payment Method:

Payments are to be made through the Becalm Counseling and Sobriety Services website via PayPal.

Payment Due Date:

Late Payment Policy: Payments not received within 10 days of the due date may incur a late fee of $25.

Cancellation and Rescheduling Policy:

Cancellations must be made at least 24 hours in advance. Cancellations made less than 24 hours before the scheduled session will incur a fee of $50.
Sessions may be rescheduled if notice is given at least 24 hours in advance. Failure to reschedule within this time limit will result in the session being considered a cancellation.

Confidentiality:

Becalm Counseling and Sobriety Services commits to maintaining the confidentiality of all client information, in accordance with applicable laws and professional standards.

Intake Paperwork:

The client acknowledges that they have completed the intake paperwork, which provides additional details on the services, terms, and conditions. The intake paperwork is considered part of this contract.

Agreement

By signing below, both parties agree to the terms outlined in this contract.

Client Signature:

Date:

Becalm Counseling Representative:

Date: