We at Mentor Network are looking
for master’s level clinicians that are interested in providing in home services
to children and families. We were wondering if you would be able to post
this in your department for graduate students to see.
All resumes may be submitted
directly to me at this e-mail, in person or by mail to the address below, or
faxed to the fax number listed below.
Thank
you for your time and consideration in this matter.
Wendy
Silva, LMHC
Clinical Lead
Ft Myers MENTOR
Supporting
Individuals. Enhancing Lives. Strengthening Relationships
13420
Parker Commons Blvd, Ste 106
Fort
Myers, FL 33912
Phone:
(239) 466-2000 Ext 18
Fax:
(239) 466-0640
CONSULTING AGREEMENT
This Consulting Agreement
(“Agreement”) is made by and between Florida MENTOR (the “Company”) and
____________________________________________, a consultant retained by the
Company as an independent contractor (“Consultant”).
The Company and Consultant agree as follows:
1.
Term of the
Agreement: This Agreement shall commence at 8:00 AM on ____________, 201__,
and shall terminate at 5:00 PM on _______________, 201__, unless terminated
earlier by either party, for any or no reason, upon thirty (30) days written
notice.
2.
Services to be
Performed: Consultant agrees to perform those consulting services for the Florida
MENTOR , Ft Myers Outpatient program, as may be requested by the Company. Exhibit “A” to this Agreement contains a
description of the general services to be provided by Consultant to the Company
under this Agreement. Consultant will at all times, and notwithstanding any
term or provision of this Agreement, have complete and sole discretion for the
manner in which the services provided under this Agreement will be
performed. The Company will have the
sole discretion to determine whether the work performed by Consultant is
satisfactory to the Company and in compliance with the quality, safety and
other standards established by the Company.
3.
Qualifications
of Consultant: Consultant represents that he/she has the qualifications and
skills necessary to perform the services under this Agreement in a competent,
professional manner, without the advice, direction, or supervision of the
Company. Consultant will provide the
Company with all documents requested by the Company to establish Consultant’s
qualifications and appropriate credentials and licenses for the services to be
performed under this Agreement. Exhibit
“B” to this Agreement sets forth the specific education, certification,
licensure and insurance requirements that Consultant must establish and
maintain in order to provide the services requested by the Company under this
Agreement.
4.
Compensation:
Consultant will be compensated for all consulting services requested by the
Company and performed by Consultant at following rates: (See Exhibit A).
5.
Status as
Independent Contractor: Consultant is an independent contractor and not an
employee or agent of the Company.
6.
Control of Work:
In the performance of its consulting services, Consultant at all times has
exclusive control over the manner, method and details of all services performed
by Consultant without supervision by the Company. Consultant will not direct, manage, supervise
or control any employees of the Company.
7.
Non-Exclusivity
of Services: During the term of this Agreement, Consultant shall be free to
perform consulting services for persons, businesses or governmental entities
other than the Company; provided, however, that in no instance shall Consultant
use or disclose any confidential information or trade secrets of the Company or
its affiliates, clients or consumers other than in the performance of
consulting services on behalf of the Company.
8.
Taxes: Consistent with Consultant’s status as an
independent contractor, the Company shall withhold no federal, state or local
income, social security, Medicare, Medicaid, or other payroll taxes from
compensation paid to Consultant under this Agreement. Consultant will obtain
the necessary taxpayer identification number from the Internal Revenue Service
(“IRS”) and provide that number to the Company. The Company will provide an IRS
Form 1099 for amounts paid to the Consultant for services performed during the
tax year. Consultant is at all times
responsible for paying when due all federal, state and local income taxes,
including estimated and self-employment taxes, incurred as a result of the
compensation paid by the Company to Consultant for services under this
Agreement. Consultant agrees to
indemnify the Company for any claims, costs, losses, fees, penalties, interest,
or damages suffered by the Company as a result of Consultant’s failure to
comply with this provision.
9.
Consultant
Certification and Affirmative Obligations: The Consultant certifies that
s/he is not presently debarred, suspended, proposed for debarment, declared
ineligible or voluntarily excluded from transacting business by or with a
Federal, state or local governmental department or agency. Throughout the term of this agreement,
including any extensions or automatic renewals thereof, the Consultant shall
immediately disclose to the Company his/her placement on the excluded
individuals list maintained by the Office of Inspector General (“OIG”). Such disclosure shall be made by written
notice in accordance with paragraph 16 of this agreement.
10.
Benefits: By
executing this Agreement, Consultant agrees that he/she is only entitled to
that compensation as set forth in paragraph 4 of this Agreement, and no other
payments, benefits, or other compensation of any kind, including worker’s
compensation and unemployment insurance benefits.
11.
Indemnification:
Consultant shall indemnify, defend and hold harmless the Company, and all of
its employees, officers, agents, and assigns, from any and all claims, demands,
losses, costs, expenses, obligations, liabilities, damages, and deficiencies
including interest, penalties, attorney’s fees, liquidated damages, and costs
that the Company may incur as a result of any negligence, active or passive fault,
or breach by Consultant.
12.
Insurance:
Consultant agrees to maintain, throughout the term of this Agreement,
professional liability insurance in the amounts of One Million Dollars
($1,000,000) per occurrence and Three Million Dollars ($3,000,000) in the
annual aggregate, and to provide evidence of such insurance to the Company upon
request.
13.
Assignments
Prohibited: This Agreement is an agreement for personal services of
Consultant who is an independent contractor as contemplated under the laws of
the State of Florida and all applicable laws of the United States of
America. Therefore, neither this
Agreement, nor any right or obligation of Consultant may be transferred,
assigned, or encumbered by Consultant without the Company’s prior written
consent, which consent may be withheld for any or no reason. Any purported transfer, assignment or
encumbrance without that consent will be void and of no force or effect.
14.
Waiver: No delay or failure by either party to
exercise any right under this Agreement, and no partial or single exercise of
that right, will constitute a waiver of that or any other right, unless
otherwise expressly provided herein.
15.
Modification: No modification or waiver of any provision of
this Agreement will be effective unless the same is in writing and signed by
the parties and then such modification or waiver will be effective only in the
specific instance and for the purpose for which it was given.
16.
Notices: Any notice required to be given under the
terms of this Agreement to a party will be in writing and sent via the United
States Postal Service, postage prepaid, and addressed to the addresses under
such party’s signature below.
17.
Forum Selection,
Venue, and Choice of Law: The parties expressly agree that the laws of the
State of Florida will govern the validity, construction, interpretation,
effect, and enforcement of this Agreement.
Each party hereby irrevocably and unconditionally consents and submits
to the personal jurisdiction of the state and Federal courts located in that
state with respect to any action relative to this Agreement and the parties
hereby waive any objection to personal jurisdiction of, venue at, and service
of process of any of the aforementioned Federal or state courts.
18.
Partial
Invalidity: In case any one or more of the provisions contained in this
Agreement should be invalid, illegal, or unenforceable in any respect, the
validity, legality, and enforceability of the remaining provisions contained
herein will not in any way be affected or impaired thereby.
19.
Entire Agreement:
This Agreement contains the entire understanding between the parties with
respect to the subject matter hereof.
There are no representations or promises other than those expressly set
forth herein. The parties acknowledge
that they are relying fully upon the contents of this Agreement and not upon
any other promises, representations or warranties, expressed or implied, not
contained herein concerning the subject matter hereof to induce them to execute
this Agreement. The headings contained
in this Agreement are for convenience only and are not intended to modify of
affect the meaning of any provision of this Agreement.
|
CONSULTANT:
By:__________________________________
Name:____________________________
Date:________________________________
Address:
__________________________________
__________________________________
__________________________________
|
COMPANY:
By:_______________________________
Name:__________________________
Date:______________________________
Address:
__________________________________
__________________________________
__________________________________
|
|
|
|
EXHIBIT “A”
The Company and Consultant agree that during the term of this
Agreement, Consultant shall perform the following services for the Company and
its clients:
1. Compensation:
Service: Your
Pay (45% of Medicaid Rates)
Individual Therapy (Medicaid): $33.00/hr ($8.25/unit-15 min)
Individual Therapy (TBOS): $28.80/hr
($7.20/unit- 15 min)
Treatment Plans $43.65
Treatment Plan Reviews $21.83
CFARS $6.75
Bio-Psychological (Licensed only) $21.60
Monthly Summaries $ 3.75 flat rate for
first summary
Any pre-approved mandatory / staffing / trainings $ 15.00 hour
Supervision (first two months every week) $ 15.00 hour
After two
months supervision will be scheduled only as needed
2. Duties:
a. Obtain and
file all required Florida MENTOR Consent forms signed by legal guardian
b. Provide
face to face counseling of clients in home, school, or other appropriate locations
c. Maintain
up to date files/records
d. Complete
a Bio-psycho-social and Treatment Plan within thirty (30) days of admit
e. Complete
Treatment Plan reviews a minimum of every ninety (90) days from signed Treatment Plan date
f. Complete progress notes following
all face to face sessions with clients
g. Complete
any required MENTOR documentation
h. Complete any required documentation for Authorizations
for treatment
i. Complete
a detailed invoice for payment listing all services rendered
j. Meet
with CS Supervisor as scheduled
EXHIBIT “B”
The following is a listing of the specific education,
certification, licensure, insurance and other requirements that Consultant must
establish and maintain in order to provide the services requested by the
Company under this Agreement:
Education:
Minimum Master’s Degree from
an accredited university or college with a major in Counseling, Social Work,
Psychology, Rehabilitation, Special Education or a human services field.
Minimum of two (2) years professional experience in providing services to
persons with behavioral illness
Certification:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Licenses:
For completion of Biopsychosocial assessments, you must
have one of the current unrestricted Florida licenses: ARNP, MD, LFMT, LCSW,
LMHC
Insurance:
See Paragraph 12 above.
_________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Other:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
