Practitioner Agreement Name (First and Last) (required) Name of Business or Practice (if none, leave blank) Your Email (required) Website or Facebook page (if non, leave blank) What services do you offer? What payment options do you offer (ie sliding scale, discounted rates, pro bono work) Where are you/your business located? Do you do distance work? If you would like to be featured in a weekly Disclosure Support spotlight and community introduction, please submit a 250 word (max) bio/introduction to your services and a picture of yourself, practice, or logo. After you submit this form, a team member will contact you via email in regard to a $20 per year contribution to become an official Disclosure Support clinician. All money collected goes directly to help cover the administrative costs of running the site and is not used for profit-building. If the suggested fee is a genuine burden for your current financial position, please express this to the team member who contacts you. By submitting this form, you agree to the following Terms and Conditions: I recognize that Disclosure Support is a community resource which should be used responsibly. This means no illegal products, services, etc. will be posted in this space. I understand that Disclosure Support is not a business entity and is not my employer. I assume all liability for my personal business and professional services. Disclosure Support is not liable for the services I provide. I agree to treat clients fairly and deliver promised services in a professional and timely manner. I agree that as a Disclosure Support practitioner, I am fully responsible and liable for the goods and services I offer. It is up to me to adhere to all legal/professional guidelines of my geographic location. I agree that if I violate the above guidelines, Disclosure Support administrators have the right to terminate my status as a “practitioner.” Δ
