Service Agreement Form

Fulcrum All -Terrain Therapeutic Services, LLC.

Mobile & Online Support

madcityfulcrum.com

608-618-6552

Service Agreement Form

By checking each box below, you acknowledge that you have carefully reviewed each section and agree to be bound by the terms and conditions outlined in this agreement.

Purpose of Agreement

This Service Agreement sets forth the terms and conditions under which services are provided by Fulcrum All-Terrain Therapeutic Services, LLC. It establishes policies related to service delivery, payment, scheduling, cancellations, safety, and client rights. Execution of this agreement indicates acknowledgment and acceptance of all terms contained herein.

1) Client Rights

Clients receiving services from Fulcrum All-Terrain Therapeutic Services, LLC have the right to:

1. Respect and Dignity - Be treated with respect, professionalism, and consideration regardless of race, ethnicity, gender identity, sexual orientation, religion, disability, socioeconomic status, or background.

   
   

2. Informed Consent - Receive clear information about the nature of services, therapeutic approaches, fees, scheduling policies, and any potential risks or benefits prior to beginning services.

   
   

3. Participation in Treatment - Actively participate in setting goals and making decisions regarding their care. Clients have the right to ask questions about the methods used and to request clarification at any time.

   
   

4. Confidentiality - Expect that personal information will be kept confidential in accordance with applicable state and federal laws, except in situations where disclosure is required by law (including but not limited to risk of harm to self or others, suspected abuse or neglect, or court order).

   
   

5. Access to Records - Request access to their records in accordance with applicable laws and professional standards.

   
   

6. Refuse or Discontinue Services - Decline specific interventions or discontinue services at any time. Clients remain responsible for payment for services already provided or reserved in accordance with this agreement.

   
   

7. Referrals - Request a referral to another provider if services are not meeting their needs or if a higher level of care is indicated.

   
   

8. File a Complaint - Voice concerns about services without fear of retaliation. Clients may request information regarding how to file a complaint with the appropriate state licensing board if they believe ethical standards have been violated.

   
   

9. Professional Credentials - Clients have the right to request information regarding the credentials, licensure, and professional background of their provider.

   
   

10. Limits of Technology (for Zoom services) - Clients have the right to be informed about the potential risks and limitations of telehealth services.

2) Client Responsibilities

Clients are expected to participate actively in services, provide accurate and complete information, and communicate openly about their needs and concerns. Clients are responsible for attending sessions as scheduled, maintaining a safe and appropriate service environment, and adhering to the policies outlined in this agreement. Therapeutic progress depends on client engagement, and specific outcomes cannot be guaranteed.

3) Service Area

Fulcrum All-Terrain Therapeutic Services, LLC., provides services to clients across multiple communities within the United States. In-person services are available only in Madison, Wisconsin, and closely surrounding areas. Clients located in all other areas, including elsewhere in Wisconsin, may receive services online. Coaching, mentoring, or peer support services are available online to any location in the United States. Therapy services are available online in Wisconsin only.

4) Location of Services

Services are provided either online via secure Zoom, or in person at a location designated by the client, such as the client’s home or another mutually agreed-upon community location. Fulcrum does not maintain a physical office location. Clients are responsible for coordinating the location and for reserving or obtaining permission to use the space when required.

5) Length of Sessions

In-person sessions are sixty (60) minutes in length. Online sessions are fifty-five (55) minutes in length.

6) Payment & Refund Policy

All services are private pay and must be paid in full at the time of booking through our website. We do not accept medical insurance and do not bill insurance companies. Services are paid out-of-pocket in advance.

HSA cards may be used as a method of payment. If you intend to request reimbursement through your HSA provider, you are responsible for submitting documentation. A paid invoice (superbill) will be provided upon request.

When you purchase a session or package, you are reserving specific dates and times in your therapist’s schedule. Because that time is set aside exclusively for you and cannot be offered to another client, all purchases are non-refundable. All sales are final.

7) Scheduling Policy

Clients do not self-schedule appointments. Appointments are scheduled after Fulcrum staff contacts the client to discuss availability. Sessions will take place no sooner than forty-eight (48) hours after that contact, except in the case of crisis appointments. This policy is in place to ensure appropriate preparation and continuity of care.

8) Recurring Appointments

A recurring appointment time slot is available only for clients who purchase multiple sessions and is not available for single-session purchases. Single-session purchases are intended as one-time appointments or consultations; therefore, a consistent or preferred time slot may not be available.

Financial Considerations:

Clients who require session-by-session payment for financial reasons but need a consistent recurring appointment are encouraged to contact Fulcrum staff to discuss possible arrangements.

9) Frequency of Sessions

To support therapeutic continuity and clinical effectiveness, therapy and coaching services are provided at a minimum frequency of once every other week, unless otherwise approved by Fulcrum staff. Clients requiring an accommodation to this policy are encouraged to discuss their needs directly with their provider.

10) Crisis Sessions

Crisis sessions may be offered within twelve (12) to twenty-four (24) hours of a client’s request, at the discretion of Fulcrum staff and subject to clinician availability. Crisis appointments are not guaranteed and may not be available for in-person sessions.

Crisis sessions are not a substitute for emergency services. If you are experiencing an emergency or are in immediate danger, please dial 911 or your local emergency number.

11) Client Cancellations

Clients must provide at least twenty-four (24) hours’ notice to cancel or reschedule a scheduled session. Cancellations made with at least twenty-four (24) hours’ notice may be rescheduled without penalty.

Cancellations made with less than twenty-four (24) hours’ notice, or no-show appointments, will incur a late cancellation fee of fifty dollars ($50.00), which will be invoiced separately.

The late cancellation fee may be waived in cases of documented emergency or illness, at the discretion of Fulcrum staff.

All approved rescheduled sessions must occur within thirty (30) days of the original appointment date or the session will expire.

Clients receiving in-person services may elect to convert their appointment to an online session if illness prevents meeting in person.

12) Fulcrum Related Cancellations

Fulcrum staff may cancel in situations where inclement weather create unsafe road conditions. In that case, the session will be rescheduled for the next available date.

Fulcrum staff may also cancel in the event they become ill. Illness related cancellations will be rescheduled for the next available date. 

13) Safety

In-person services provided in a client’s home or other designated location are not available in situations involving active domestic violence. Clients are responsible for ensuring that the service location is safe and appropriate for service delivery.

Firearms must be secured and not present in the service area while Fulcrum staff are on the premises. Illegal activity of any kind, including the use or presence of illegal substances, is strictly prohibited during service visits. The use or presence of alcohol is also prohibited during all service sessions.

Fulcrum All-Terrain Therapeutic Services, LLC reserves the right to discontinue or refuse services, without credit or refund, if illegal activity is present or if the environment is determined to be unsafe, as described above.

Clients are responsible for securing any pets that display aggressive or challenging behavior prior to and during the service session.

14) Minors

An adult legal guardian must be present for the initial appointment. For all in-person services conducted in the home or community, a parent or legal guardian must remain on-site or in close proximity and be immediately reachable, unless an alternate arrangement has been approved in advance by the therapist.

Acknowledgment and Agreement

By signing below, I acknowledge that I have read this Service Agreement in its entirety and understand its contents. I agree to all terms and conditions contained herein, including but not limited to payment obligations, cancellation policies, refund policies, safety requirements, and service limitations. I understand that this agreement is legally binding and governs all services provided by Fulcrum All-Terrain Therapeutic Services, LLC.