NEW LIFE COUNSELING P.C.             121 WEST MAGNOLIA, BELGRADE, MT 59714 (406) 388-2727

CHRIS McBEE M.S. LCPC

The scope of services covered by this contract is limited to the reduction of those obsessive and/or compulsive symptoms reported prior to the beginning of Exposure and Response-Prevention Treatment (ERP) to New Life Counseling P.C. by the subject on standardized assessment instruments, which would appropriately contribute to a correct diagnosis of Obsessive Compulsive Disorder (OCD) using the specific criteria set forth within the Diagnostic And Statistical Manual Of Mental Disorders, Fourth Edition (subsequently referred to as the DSM-4).

The services offered and provided under this contract are limited to the following:

1. Assessment of OCD symptoms from the subject's, and/or other interested party's reports.

2. Diagnosis, or non-diagnosis of OCD using DSM-4 criteria.

3. Psycho-education of the client and/or other interested parties relating to OCD and ERP Therapy.

4. Determination of the symptoms to be targeted for ERP Therapy.

5. ERP Therapy exercises.

6. Assessment of the subject's therapy skills development.

7. Assessment of the client's post-treatment anxiety level specific to symptoms targeted by ERP.

The intent of treatment services offered under this contract is to reduce (not eliminate) the magnitude of anxiety specifically related to the DSM-4 criteria symptoms reported to New Life Counseling P.C. by the subject, on standardized assessment instruments, prior to the beginning of ERP Therapy.

It is understood and agreed by all the parties to this contract that:

a. ERP Therapy is NOT A CURE for OCD and is intended to REDUCE, NOT ELIMINATE symptoms.

b. The total elimination of anxiety related to the subject's reported OCD symptoms is unlikely and neither guaranteed nor implied.

c. This ERP treatment is not intended to reduce anxieties the subject may experience which are related to stress-producing events or relationships in the subject's life but which:

c1. do not contribute to a correct diagnosis of OCD by DSM-4 criteria.

c2. contribute to a DSM-4 diagnosis other than OCD.

c3. may be related to the subject's use, abuse, or dependence upon controlled substances, alcohol, herbal remedies, dietary supplements, or medications prescribed for the use of the subject or another person.

c4. may be reasonably attributable to the subject's psychosis or general medical condition.

c5. may be related to a subject's developmental disorder.

c6. may be related to events, conditions, or symptoms not reported by the subject to New Life Counseling P.C. prior to the beginning of ERP Therapy.

d. Due to the fluctuating and chronic nature of OCD symptoms, some symptoms (including, but not limited to depression or suicidality) may worsen at some time following treatment and neither New Life Counseling P.C. nor Chris McBee shall be held liable should this occur.

e. Neither New Life Counseling P.C. nor Chris McBee shall be liable for changes of any nature in a subject's condition which existed prior to the engagement of New Life Counseling P.C. for services.

f. In the event that the treatment subject is female, or upon request by New Life Counseling P.C., the parties to this contract shall allow the immediate and continuous presence of a female New Life Counseling P.C. co-worker, (or a substitute acceptable to all parties) during all phases of treatment and agree to allow the additional reasonable fees associated with the presence of that co-worker.

g. The subject, parent, guardian, or financially responsible party may cancel this contract at any time and for any reason. If any of these subjects cancels, performance of this contract by New Life Counseling P.C. will be considered sufficient if any of the seven services offered have been completed.

h. Following the completion or termination of services New Life Counseling P.C. shall provide to the financially responsible party a statement listing all of the charges made against the retainer fee along with any unused balance of the retainer fee within 10 business days of the end of services.

i. Any unused balance of the retainer fee due to the financially responsible party shall be returned to the original payor within 10 business days following the end of services.

j. Because of the chronic nature of OCD, the difficulties of treatment, and the central collaborative role of the subject, no guarantees about the degree of success of the treatment are made or implied by New Life Counseling P.C. and the signatures of the parties represent informed consent for treatment.

k. This contract will be interpreted, adjudicated, and enforced under the laws of the state of Montana.

The subject, subject's guardian, or subject's representative, upon signing this contract agrees to engage the services of New Life Counseling P.C. by the payment of a retainer fee in the amount of $________ prior to the delivery of any services. Fees for chargeable activities shall be deducted from the retainer fee.

The parties agree that charges against the retainer fee may be made for the purposes of transportation, lodging, meals, assessment, diagnosis, treatment planning, treatment provision, treatment evaluation, psycho-education for the client or interested parties, fees paid to co-workers allowed under this contract, professional consultations, coordination of services with other providers, preparation of reports, insurance claim submissions, or any other expense reasonably associated with the services to be provided under this contract.

New Life Counseling P.C. agrees to return portions of the unused retainer in accordance with the following conditions.

100% of the unused retainer will be returned if all planned therapy services have been delivered and/or New Life Counseling P.C. determines additional services are unnecessary, impossible, or clinically not recommended.

100% of the unused retainer will be returned if none of the activities listed above as chargeable activities have occurred and the subject, guardian, or financially responsible party cancels the therapy.

100% of the unused retainer will also be returned if, due to clinical factors, ethical considerations, death, illness, accident, act of God, legal restriction, or events beyond their control New Life Counseling P.C. is unable to perform the contracted services or satisfactorily reschedule the contracted services.

100% of the unused retainer will also be returned if clinical considerations suggest to New Life Counseling P.C. that the therapy services offered are not in the subject's best treatment interests.

80% of the unused retainer will be returned if New Life Counseling P.C. has scheduled the therapy for the subject, rescheduled other clients, but not performed any other chargeable activities and the subject, guardian, or financially responsible party cancels the therapy.

50% of the unused retainer will be returned if New Life Counseling P.C. has scheduled the client's therapy, rescheduled other clients, and made reservations for commercial travel and the subject, guardian, or financially responsible party cancels the therapy.

0% of the unused retainer will be returned if New Life Counseling P.C. employees have scheduled the client's therapy, rescheduled other clients, made commercial travel reservations, have performed any of that travel, and the subject, guardian, or financially responsible party cancels the therapy.

The parties to this contract understand and agree that New Life Counseling P.C. will perform the services listed in this contract beginning on the date: _______________ and ending on the date: ________________ .

Clarifications or qualifications necessary to accurately describe irregularities or breaks in the time of performance are described below. If no entry is made it is assumed the time of performance shall be at any time between and inclusive of the dates entered above. ____________________________________________________________

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PARTIES TO THE CONTRACT

The parties to this contract are limited to the direct subject of the treatment services offered under this contract, the subject's parents or guardian if the subject is a minor, the individual or entity assuming the financial responsibility of payment for the services, Chris McBee, and New Life Counseling P.C. No other entities, individuals, groups, or organizations are a party.

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Print the name of the direct subject of the treatment services. Is the subject a minor? __________

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Signature of subject if not a minor.                                                  Date signed

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Print the name of parent or guardian if subject is a minor.

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Signature of parent or guardian if subject is a minor.                       Date signed

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Print the name of the financially responsible party.

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Signature of financially responsible party.                                  Date signed

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New Life Counseling P.C. Authorized signature                        Date signed

Chris McBee, President