1991-23
~
. -~LAKE/SUMTEAENTAL HEALTH CEN. AND HOSPITAL
EMPLOYEE ASSISTANCE PROGRAM AGREEMENT
REFERRAL
9/- 023
This Employee Assistance Program Agreement (the "Agreement"), made as of the 6th
day of August
1991, by and between Lake/Sumter Mental Health Center and
Hospital, a Florida nonprofit corporation with its principal office at 215 North third
Street, Leesburg, Florida (hereinafter referred to as liThe Center") and
City of Clermont
(hereinafter referred to as liThe Company").
WHEREAS, the Parties wish to enter into an Agreement under which the Center will
administer a program and provide certain services to assist the Company's employees,
to be called the Employee Assistance Program ("EAplI).
NOW, THEREFORE, in consideration of the mutual duties, covenants and obligations
of the parties, the Company and the Center hereby agree as follows:
1. Conduct education and training of staff in the areas of substance abuse
(i.e., addiction, signs, symptoms, documentation, confrontation) and or
mental health (i.e., stress management, emotional well being, attitude, team
wor k) .
2. Consultation for services wi 11 be provided by Center professional staff
(Masters level or Certified Addictions Professionals) in the areas of staff
,
development. The Center'~
3. Services shall Fee Schedüle
be contracted on an hourly basis at the rate of $ ~ per
håur. This rate shall be inclusive of all materials, handouts, and
distributions made available through the presenter(s). Other Center services
shall be available at previously established rates.
4. The term of this Agreement shall be for one (1) year from 8/6
, 1991 ,
through 8/6
1992 . Either party may terminate this Agreement upon
ninety (90) days written notice to the other.
.
EAP:015:N:I0/90
·
~
e
e
EMPLOYEE ASSISTANCE PROGRAM AGREEMENT
Page 2 of 2
5. The parties agree that the Center is an independent contractor performing its
obligations hereunder. In no event will the Company be liable for any injury
or damages to employees or members of their families or others arising out of
any acts or omissions of the Center in performing its services under this
Agreement. The Center will not be liable for any injury or damages to
employees or members of their families arising out of any acts or omissions
by the Company under this Agreement. Each party agrees to idemnify and hold
the other harmless against claims arising out of the acts and omissions of
the other party and its employees under this Agreement.
IN WITNESS WHEREOF, the parties have caused this Agreement to be duly executed by
their duly authorized representatives as of the date first written above.
LAKE/SUMTER MENTAL HEALTH CENTER AND HOSPITAL
By:
, -
~
City of Clermont
P.O. Box 120219
Clermont,-FL 34712-0219
BY:~ 0 ~~
EAP:015:N:I0/90
*** SLIDING FEE SCALE *** e
e
*** Initial Evaluation ***
BASED ON - 90.00 CHARGE MINIMUM AMOUNT - 40.00 8/23/91
***** It is customary to pay for services when they are rendered *****
--------------------------------------------------------------------------------
NUMBER OF DEPENDENTS - 1
2
3
4
5
6
7
8
--------------------------------------------------------------------------------
GROSS MONTHLY
FAMILY INCOME
CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT
FEE FEE FEE FEE FEE FEE FEE FEE
--------------------------------------------------------------------------------
Under $599
40.00 40.00 40.00 40.00 40.00 40.00 40.00 40.00
--------------------------------------------------------------------------------
$600-$999
54.00 40.00 40.00 40.00 40.00 40.00 40.00 40.00
--------------------------------------------------------------------------------
$1000-$1499
63.00 63.00 54.00 40.00 40.00 40.00 40.00 40.00
--------------------------------------------------------------------------------
$1500-$1999
81.00 72.00 63.00 54.00 40.00 40.00 40.00 40.00
--------------------------------------------------------------------------------
$2000-$2599
90.00 90.00 81.00 72.00 54.00 45.00 40.00 40.00
--------------------------------------------------------------------------------
$2600-& OVER
90.00 90.00 90.00 90.00 90.00 90.00 90.00 90.00
--------------------------------------------------------------------------------
*** SLIDING FEE SCALE ***
e e
*** Individual Therapy ***
BASED ON - 70.00 CHARGE MINIMUM AMOUNT - 35.00 8/23/91
***** It is customary to pay for services when they are rendered *****
--------------------------------------------------------------------------------
NUMBER OF DEPENDENTS - 1
2
3
4
5
6
7
8
--------------------------------------------------------------------------------
GROSS MONTHLY
FAMILY INCOME
CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT
FEE FEE FEE FEE FEE FEE FEE FEE
--------------------------------------------------------------------------------
Under $599
35.00 35.00 35.00 35.00 35.00 35.00 35.00 35.00
--------------------------------------------------------------------------------
$600-$999
42.00 35.00 35.00 35.00 35.00 35.00 35.00 35.00
--------------------------------------------------------------------------------
$1000-$1499
49.00 49.00 42.00 35.00 35.00 35.00 35.00 35.00
--------------------------------------------------------------------------------
$1500-$1999
63.00 56.00 49.00 42.00 35.00 35.00 35.00 35.00
--------------------------------------------------------------------------------
$2000-$2599
70.00 70.00 63.00 56.00 42.00 35.00 35.00 35.00
--------------------------------------------------------------------------------
$2600-& OVER
70.00 70.00 70.00 70.00 70.00 70.00 70.00 70.00
--------------------------------------------------------------------------------
*** SLIDING FEE SCALE ***
~PhYSChiatric Evaluations
*
e
BASED ON - 120.00 CHARGE
MINIMUM AMOUNT - 35.00
8/23/91
***** It is customary to pay for services when they are rendered *****
--------------------------------------------------------------------------------
NUMBER OF DEPENDENTS - 1
2
3
4
5
6
7
8
--------------------------------------------------------------------------------
GROSS MONTHLY
FAMILY INCOME
CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT
FEE FEE FEE FEE FEE FEE FEE FEE
--------------------------------------------------------------------------------
Under $599
35.00 35.00 35.00 35.00 35.00 35.00 35.00 35.00
--------------------------------------------------------------------------------
$600-$999
72.00 48.00 35.00 35.00 35.00 35.00 35.00 35.00
-------------------------------------------------------------------------~------
$1000-$1499
84.00 84.00 72.00 48.00 36.00 35.00 35.00 35.00
--------------------------------------------------------------------------------
$1500-$1999
108.00 96.00 84.00 72.00 48.00 36.00 35.00 35.00
--------------------------------------------------------------------------------
$2000-$2599
120.00 120.00 108.00 96.00 72.00 60.00 48.00 35.00
--------------------------------------------------------------------------------
$2600-& OVER
120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00
--------------------------------------------------------------------------------
.* SLIDING FEE SCALE *** e
*** Medication Check ***
BASED ON - 30.00 CHARGE MINIMUM AMOUNT - 6.00 8/23/91
***** It is customary to pay for services when they are rendered *****
--------------------------------------------------------------------------------
NUMBER OF DEPENDENTS - 1
2
3
4
5
6
7
8
--------------------------------------------------------------------------------
GROSS MONTHLY
FAMILY INCOME
CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT
FEE FEE FEE FEE FEE FEE FEE FEE
--------------------------------------------------------------------------------
Under $599
6.00
6.00
6.00
6.00
6.00
6.00
6.00
6.00
--------------------------------------------------------------------------------
$600-$999
18.00 12.00
6.00
6.00
6.00
6.00
6.00
6.00
--------------------------------------------------------------------------------
$1000-$1499
21. 00 21. 00
18.00
12.00
9.00
6.00
6.00
6.00
--------------------------------------------------------------------------------
$1500-$1999
27.00 24.00 21.00
18.00
12.00
9.00
6.00
6.00
--------------------------------------------------------------------------------
$2000-$2599
30.00 30.00 27.00 24.00
18.00 15.00
12.00
6.00
--------------------------------------------------------------------------------
$2600-& OVER
30.00 30.00 30.00 30.00 30.00 30.00 30.00 30.00
--------------------------------------------------------------------------------
.*
SLIDING FEE SCALE
***
e
*** Group Therapy ***
BASED ON -
25.00 CHARGE
MINIMUM AMOUNT -
6.00
8/23/91
***** It is customary to pay for services when they are rendered *****
--------------------------------------------------------------------------------
NUMBER OF DEPENDENTS - 1
2
3
4
5
6
7
8
--------------------------------------------------------------------------------
GROSS MONTHLY
FAMILY INCOME
CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT CLIENT
FEE FEE FEE FEE FEE FEE FEE FEE
--------------------------------------------------------------------------------
Under $599
6.00
6.00
6.00
6.00
6.00
6.00
6.00
6.00
--------------------------------------------------------------------------------
$600-$999
15.00 10.00
6.00
6.00
6.00
6.00
6.00
6.00
--------------------------------------------------------------------------------
$1000-$1499
17.00 17.00
15.00
10.00
7.00
6.00
6.00
6.00
--------------------------------------------------------------------------------
$1500-$1999
22.00 20.00
17.00
15.00 10.00
7.00
6.00
6.00
--------------------------------------------------------------------------------
$2000-$2599
25.00 25.00 22.00 20.00
15.00
12.00
10.00
6.00
--------------------------------------------------------------------------------
$2600-& OVER
25.00 25.00 25.00 25.00 25.00 25.00 25.00 25.00
--------------------------------------------------------------------------------
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