Service Agreement — fill & sign

Complete each section below, review the acknowledgments, then electronically sign.

Preview the fillable PDF agreement →

Section 1

Agreement Information

Agreement date *

Provider legal/business name *

Client / responsible party name *

Client email *

Client phone *

Client mailing address

Participant name (if different)

Parent/guardian/authorized representative (if applicable)

Program start date

Program end date

Emergency contact name

Emergency contact phone

Preferred communication channel

Section 2

Service Package Selection

Selected package *

Total fee

Payment schedule

Custom package notes

Section 3

Scope and Boundaries

This service is behavioral support, data tracking, and coping plan adjustment. It is not therapy, medical care, medication management, or crisis support.

Section 4

Fees and Payment Terms

Payment is due per the schedule above. Cancellation and refund terms will follow the attorney-reviewed PDF once attached. [Placeholder for full payment terms.]

Section 5

Safety and Crisis Boundaries

Safety & Scope

This service does not replace therapy, medical care, crisis support, or medication management. The purpose is to organize behavioral data, strengthen response strategies, and help clients communicate patterns more clearly with their care team.

If there are unsafe thoughts, severe symptoms, chest pain, major breathing concerns, dangerous sedation, medication taken differently than prescribed, or medication mixed with alcohol/sedatives, use medical or crisis support before coping tools or routine messaging.

Section 6

Privacy and Data Use

Sensitive behavioral data (nighttime episode details, medication timing, crisis notes) will only be shared through the approved secure method once configured — not via this web form.

Section 7

Client Acknowledgments

I understand this service is behavioral support and data organization, not therapy, medical care, medication management, diagnosis, or crisis response.I understand messages, forms, and check-ins are not monitored 24/7 and should not be used for emergencies or imminent safety concerns.I understand medication tracking is for observation and communication only; I will not change medication based on this service unless directed by a licensed prescriber.I agree to provide accurate information, complete assigned tracking as reasonably possible, and seek appropriate professional support when needed.I understand the selected fee, payment schedule, cancellation policy, and refund terms stated in this agreement.I consent to electronic completion, electronic signature, and electronic delivery of this agreement.

Section 8

Electronic Signature

Client signature (typed name) *

Client signature date *

Guardian signature (typed name, if applicable)

Guardian signature date

Provider signature (typed name)

Provider signature date

Care coordination provider/team (optional)

Client initials for care coordination authorization

Attachments / integrations placeholders: attorney-reviewed PDF contract, Stripe checkout link, and Calendly/Acuity scheduling link can be wired here.