Forms

Counseling Services Agreement Form

This agreement outlines the partnership between Community MindEd and the provider named below for the provision of therapeutic services through Community MindEd's scholarship program.

1. Purpose

Community MindEd agrees to fund therapeutic services for eligible individuals through participating licensed providers, promoting accessible, high-quality mental health care for those facing financial barriers.

2. Terms of Agreement

The provider agrees to:

  • Maintain current licensure in the State of Montana and carry active professional liability insurance.
  • Provide therapy services that align with best clinical practices and the provider's professional scope.
  • Accept Community MindEd's approved reimbursement rate of $125 per session, not to exceed a total of $1,250 per client.
  • Provide up to 10 total sessions per client under this agreement.
  • Not bill the client's insurance or accept other payment for the same sessions funded by Community MindEd.
  • Submit attendance or progress confirmations upon request (limited to session completion verification; no clinical content).

Community MindEd agrees to provide reimbursement for completed sessions per the agreement herein.

3. Independent Practice

The provider is an independent contractor and is solely responsible for the delivery and quality of all services provided. Nothing in this agreement shall be construed to create an employer–employee or agency relationship between the provider and Community MindEd.

4. Duration

This agreement becomes effective on the date entered below and will remain in effect until terminated by either party with written notice.