Below is a sample of the sort of contract you will receive from your peak states therapist.



Pay for Results Agreement Form
Revision 1.0, August 29, 2009
© 2012 by Dr. Grant McFetridge



Client Name:                                                Signature:


Certified Therapist:                                     Signature:


Date:


Symptoms and the “Pay for Results” Fee
Below is your copy of what I (your therapist) agree to treat. We start by finding out what symptoms are bothering you, and then we list the set of symptoms that they feel they can heal. The fee is set on these symptoms: you have to decide if they are worth the cost, If we are unable to heal the agreed upon symptoms, then there is no fee. The fee is non-refundable after two weeks from the last treatment.

Post Treatment Care
After treatment, it is possible that you will have feelings come up. This is normal and to be expected, and we treat that on the second session. Many of the changes from this treatment will take time to manifest – for example, social interactions may change. Please wait at least a week before you make any major decisions in your life based on the changes that have occurred in you.

Description of the client’s problem symptoms:





Symptoms that the therapist agrees to treat:






Fee (payable in advance of treatment):





Revision History
1.0, Sept 1, 2012: First draft of this webpage.