Church Case Agreement

Church Case Agreement
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
This letter confirms the agreement made between Church Name* and Boundless Hope.
This single case agreement is intended to serve the case of Client Name*   Client DOB*   and will terminate upon the completion of authorized session or expiration of authorized dates of services.
The church is providing a total of      53-minute sessions covered at      .
This agreement is valid through   Expiration Date*   or completion of authorized services, whichever comes first.
Boundless Hope Provider
If you select "No Preference/Any Clinician," You are authorizing Boundless Hope to bill for any clinician selected by the client listed herein.
Church Billing Contact :

Full Name*

Email*  Phone Number*
Is there anything further our team should know about this agreement?
Should be Empty: