Agreement to Forensic Services

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Patient's Name
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I wish to contract with the Mood Treatment Center for legal services including testimony, consultation with my attorney, and/or preparation of documents. I understand that these services are billed on an hourly basis and that insurance does not cover these charges.

I agree to pay for them according to the rate schedule below:

Hourly Rates

Physician (MD) $300
Nurse Practitioner (NP, PA) $175
Psychologist (PhD, PsyD) $200
Masters Level Therapist (MA, MS, LPC, MSW, LMFT, LPA, LCAS) $150
In signing below, I agree to these terms and also give Mood Treatment Center permission to communicate with my legal representatives.
Include the names of anyone you would like us to communicate with at the firm.
I understand that I have a right to revoke this authorization at any time.
I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Mood Treatment Center.
I understand that the revocation will not apply to information that has already been released in response to this authorization.
I understand that this authorization for disclosure is voluntary and that I need not sign this form to ensure healthcare treatment.
Information to release
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