I understand and agree to be treated by a therapist who is an Associate and is not an employee of Dunham Counseling Center, Ltd. but is an independent contractor renting space and services from Dunham Counseling Center, Ltd.

I understand and accept that Dunham Counseling Center, Ltd. handles all administrative and billing work for the Associate, including but not limited to submitting bills to my medical insurance coverage agency or organization. I understand and accept that the bills will be submitted in the name of Dunham Counseling Center, Ltd. with the Associate identified on all claims as the individual provider, and that the Associate will receive all monies for any services rendered to me.

I understand and agree that Dunham Counseling Center, Ltd. is not responsible for any treatment and my clinical records. I understand and agree that the Associate is solely responsible for my treatment and clinical records.

I understand and agree that in the event the Associate is unable or refuses to continue providing services to me, that the Associate is responsible for referrals for continuing treatment. Dunham Counseling Center, Ltd. may but is not required to assist me in finding an alternative professional to continue my treatment. I have entered my signature below to show that I understand all these  statements of the duties and limitations of Dunham Counseling Center, Ltd.

Your therapist has a late cancellation policy of 24 hours notice.  If you do not show or cancel within 24 hours you will be charged. Cancellation fees vary by therapist. Please discuss the cancellation fee amount with your therapist.

The typed name acknowledges your consent to this Agreement to Receive Services at Dunham Counseling Center, LTD.