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SAMPLE AGREEMENT
(note pp = Private Practice)
 
Effective October 8, 2009, tcc has become the Administrative Manager of John Doe’s pp.
 
Answering the Phones and Intakes
All phones will be answered in the same manner and with the same words as now. Just be alert to omit any questions that relate solely to dui, sos, of dv. Fill in all the Customer Center data, again omitting dui, sos, dv related data. I’ve not taken the time to go through this entire process so let me know of any questions. Let John Doe’s clients know that payment is expected prior to the session, unless other arrangements have been made. (John Doe, let us know if you want anything different said, but please keep it simple and assume the function of explaining any policies to the clients yourself ). Defer any insurance questions to John Doe. John Doe will handle all matters to do with insurance. If the question of tcc’s role comes up, you should respond that tcc is the “Administrative Manager for Mr. Doe’s practice”.
Mr. Doe has provided our intake staff with some laymen’s terms to listen for, as a help in setting appointments. Some clients will indicate that they were referred by the insurance company. Schedule all of these patients. Most patients will indicate that they need"treatment for depression or anxiety." Others will just say that they have been "feeling stressed out" and they got my name from the ad, or the yellow pages. Still there are others that will say "I have been feeling suicidal and I have to get some help" YOU CAN CONTACT ME IMMEDIATELY IF WE GET CALLS LIKE THIS. We will also utilize 911, referrals to local emergency room, and local crisis lines, as appropriate. There will also be calls from veterans that will indicate "I would like to talk to someone about PTSD." Any one that indicates that he is connected with the VA should be scheduled. I don't expect to get much in the way of couples counseling, but feel free to schedule them if they indicate that they have any sort of mental health issues or substance abuse issues. Do not schedule those that are just interested in relationship counseling, for example marriage counseling. Some will call and state that they have a "dual diagnosis", meaning that they use drugs and have a mental health issue. You may schedule all of these patients. Some of the key words to look for are “DEPRESSION, ANXIETY, SUBSTANCE USE, PTSD, STRESSED OUT, SUICIDAL, DUAL DIAGNOSIS, MOOD DISORDER AND VETERAN”.
 
Scheduling Appointments
Scheduling should be done, just as it is now for any counselor. You will book all of tcc appointments intermingled with pp appointments within John Doe’s (this example happens to be for John Doe, who is also a TCC employee) latest assigned time schedule given out recently. John Doe may occasionally have a client call in, having gotten John Doe’s permission to book an appointment at some other time that the room is free.
 
Daysheets (Daily Appointments)
John Doe’s daysheets will have the new Items incorporated and intermingled with tcc Items. All of John Doe’s pp appoints will be for 1 hour, except the a substance abuse treatment planning session, which will probably not be the first session. John Doe will instruct his client to call in and set up a treatment planning appointment as soon John Doe determines that the client is entering substance abuse treatment. When John Doe is treating someone for substance/alcohol abuse he will be working under tcc’s license. All of tcc’s substance, abuse policies, paperwork, and supervision will be followed as if the client were a tcc client. It Will be more helpful than ever if clients pay each time. It will keep the accounting simpler.
 
Dual Diagnosed Clients
John Doe be seeing clients who are dually diagnosed with a mental health problem as well as a substance abuse problem. The substance abuse portion of the treatment will be under tcc’s license and will follow all of tcc’s paperwork protocol and clinical policies. This means that a treatment planning session and subsequent fixed schedule will have to take place. I’m suggesting to John Doe that he use our substance abuse treatment paperwork also for his mental health sessions. Donna is planning to meet with John Doe to go over items from our recent inspection, so I’m asking her to help John Doe incorporate his mental health goals and progress notes using the exact same paperwork.
 
Client Insurance Coverage
John Doe will handle all aspects of insurance coverage, if any, for his clients. Tcc does not do any insurance billing, but will provide our customary invoice. If the insured is actually a client of tcc’s, our current practice of Dr. Hess signing the claim for will continue, but tcc will not wait for payment from the insurance company. Where John Doe is working under tcc’s DASA license, Tcc Will cooperate to see if Blue Cross coverage may be of some help to John Doe for substance abuse sessions.
 
Payroll
During the payroll/excel process done each week for payroll, the number of John Doe’s hours spent generating revenue under tcc’s license will be recorded. Based on these hours, John Doe Will be charged $xx per hour for pp substance abuse hours, and $x.xx per hour for pp dual diagnosis hours.
 
Distributing John Doe’s pp Income
A “Private Practice Income Distribution Report - John Doe” will be generated monthly to determine John Doe’s income to be distributed. John Doe’s pp client fees charged (qb Items) will be displayed as Revenue in the report. Tcc “License Charges” to John Doe will be displayed as expenses/deductions in the report. To avoid distributions being paid out of tcc funds, the amount of uncollected pp client fees will be displayed as “Deferred Distribution” in the report, and treated as a deduction in the report. Should there be any other items paid/deductions, or collected/additions, on John Doe’s behalf they will be explained in the report. A net positive balance will indicate the amount to be distributed to John Doe. A net negative balance will indicate no distribution available (likely due to too many uncollected fees). TCC does not prepare any financial statements for John Doe.
 
Marketing
Tcc and John Doe intend and agree to, whenever appropriate, market each other’s services.
 
Web site: The Counseling Center.net
John Doe’s private practice will be represented on tcc’s web site; the manner of which is presently being designed.
 
Cooperative Non-Compete Agreement
Tcc and John Doe will agree not to compete with each other for the same business, during the life of this agreement, nor for 3 years following the termination of this agreement. The non-compete clause of this agreement shall be limited to within a distance of 25 miles from their respective offices of operation.