Treatment Agreement | Carta Coaching

TREATMENT AGREEMENT CARTA COACHING

Format conform to the WGBO standards

Client’s full-name (surname+name) : ............................................ .................................................. ..................

(If applicable: please also state maiden name!)

Address: ................................................ .................................................. ................

Zipcode city: .......... ...................................

Telephone: .................................... Civil status: ......... ............................

Date of birth: .................................... Gender: ☐ Male ☐ Female

Profession: .................................... Work address: .......... .....................................

GP’s name: ………………………………

Health insurance company-name: ……………………………………………….

Policy number health insurance: ...............................................

Do you give permission to obtain and exchange information from the doctor and / or referrer?

☐ Yes ☐ No.

Do you give permission to get in touch and inform the doctor and / or referrer after the treatment?

☐Yes ☐ No.

_________________________________

Do you agree with the rates of € 120 for the first session (intake interview 60 minutes) and € 90 per regular follow-up session?

☐ Yes ☐ No.

How do you pay for the consultations?

☐cash ☐ by bank (after receipt of an invoice)

Number of sessions we have been arranging ……….

Nature of the problem

What is your request for help?

......................................... .................................................. ....................

Do you also have complaints (physical / emotional)? ☐ Yes ☐ No.

If so, what is / are they: ......................................... .................................................. ....................

Since when have you been bothered by this complaint (s)? .................................................. ......................

3 A.

Which doctors have you consulted? ☐ GP ☐ Specialist ☐ Psychiatrist

......................................... .................................................. ....................

3 B.

Have you also consulted (an) other care provider (s)? ☐ Yes ☐ No.

......................................... .................................................. ....................

If so, (who) which?: ......................................... .................................................. ........................

_________________________________

3 C.

Has a diagnosis been made? ☐ Yes ☐ No.

If so, by whom? ☐ GP ☐ Specialist ☐ Psychiatrist

☐ Counselor

☐ Specialist ☐ Psychiatrist

What treatment goal does the treatment have?

Further information that may be important for treatment:

Any adverse consequences resulting from the withholding of information present in the medical file of the GP are the responsibility of the client.

The payment conditions on page 4 are standard with this treatment agreement!

Date: ................................................ ........ Place: ........................................ ..........................

Name of therapist: Cristiana Carta

NVPA Registration Number: 104706

Signature of therapist (e) Signature of client (e)

In the case of a minor, both parents or guardian (s)

_________________________________

PAYMENT TERMS OF THIS TREATMENT AGREEMENT

Article 1

All provisions of the WBGO Act (Book 7, Title 7, Section 5 of the Civil Code, except in the Civil Code to be found in Government Gazette No. 837 of 1994) are applicable to this treatment agreement.

Article 2

If the client is unable to attend, an appointment with an NVPA therapist must be canceled 24 hours before the time of the appointment.

In case of late cancellation or non-cancellation, the consultation will be charged.

Article 3

The invoice sent by the therapist must be paid within 14 days of the due date.

Article 4

In the event of non-payment within 14 days, the client is in fault and the therapist may charge 1% interest per month without further notice of default.

Article 5

During the 14 days and after the therapist is entitled to send payment reminders through the accountancy system invoice2go.com.

Article 6

If the bill has not yet been paid within 14 days after sending the payment reminder, the therapist is entitled to take a collection measure. The costs of the collection measure are for the expenses of the client.

Article 7

In order to take measures in accordance with articles 4, 5 and 6 for payment, it applies in full that this must be done in good faith and in reasonableness and fairness.

Force majeure on the part of the client must be able to be discussed with the therapist at all times.

The damage to the assistance process due to non-payment should be limited as much as possible by the therapist and client.

This arrangement is part of the standard treatment agreement