This Concierge Mental Health Services agreement dated _____/_____/_____ between Avera Behavioral Management, Inc. (henceforth referred to as the "Provider") and _________________________ (henceforth referred to as the "Responsible Party for the Resident") is for the purpose of providing on-site, on-call, and on-line  ___ Caregiver Education  ___ Behavioral Monitoring ___ Staff Training  ___Competency Evaluation   ____ Clinical Assessment ____ Case Management services for the aforementioned Responsible Party. Any relevant and reasonable behavioral, mental, or clinical service or item deemed medically neccessary and provided directly (face-to-face) with the Resident including: (1) Psychiatric diagnostic interviews (2) Individual psychotherapy (3) Family psychotherapy and (4) Pharmacologic management will be billed against the Resident's Medicare account. Medicare copays and deductables will be billed directly to the Responsible Party of the Resident and payment will be expected at the time of the visit. Any administrative, informational, clerical, legal, educational, technical, instructional, testimonial, referral, environmental, reporting, or training services executed by the provider and delivered directly to, for the benefit of, or at the request of a family member, facility staff or other party consisting of and incuding but not limited to: (1) Environmental Interventions on behalf of the psychiatric Resident with agencies and institutions for medical management purposes (2) Psychiatric evaluation of reports, records, or other data for diagnostic purposes (3) Interpretation or explanation of accumulated data to family members or other responsible parties or advising them on how to assist the Resident (4) Preparation of progress reports regarding the Residents's psychiatric status for other physicians, agencies, or insurance carriers (5) Physician Telephone consultations, Physician/Team Conferences, or E-mail correspondence will be billed to the Responsible Party of the Resident at an hourly rate of $____________, daily rate of $__________, or a monthly rate of $__________. Payables shall accrue and will be invoiced on the last day of every month and be paid by the Responsible Party of the Resident to the provider by the 15'th day of the following month as compensation for these ancillary services for a period of ______ month(s) beginning from the signed date of this agreement. This agreement can be terminated without cause or fault by either party. If in agreement please print, date, sign, and fax to 770-973-3587 or scan and e-mail to: averamgmt@bellsouth.net

____________________                                                      ____________________________

DATE                                                                                          Responsible Party for Resident

____________________                                                     _____________________________

DATE                                                                                         Avera Behavioral Management, Inc.