Partnership Initial Enrollment

Name of Organization*

Please Enter Contact Person Name*

First NameLast Name

Please Verify Contact Email Address*

example@example.com

Contact Mailing Address*

Street Address

Street Address Line 2

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Postal / Zip Code

Contact Phone Number*

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Purchase Your Plan*

Coverage for up to 10 clients annually Product Image

Coverage for up to 10 clients annuallyComprehensive Client Care: Evaluation, diagnosis, treatment, and ongoing management for each enrolled client. Technology Tools: Telehealth access, symptom tracking, and automated care solutions. Onboarding & Training: Full support for seamless integration into your organization. Partner Success Support: Dedicated success manager for ongoing assistance and optimization. Custom Reporting: Regular insights and outcomes tracking for organizational transparency. Terms and Conditions: Fees are billed annually upfront. Services are provided for the agreed client capacity within the year. Additional client capacity can be purchased mid-year at prorated rates. Renewals occur automatically unless canceled with 30 days’ written notice before the term’s end.

$10,000.00 for each year

Coverage for up to 100 clients annually Product Image

Coverage for up to 100 clients annuallyComprehensive Client Care: Evaluation, diagnosis, treatment, and ongoing management for each enrolled client. Technology Tools: Telehealth access, symptom tracking, and automated care solutions. Onboarding & Training: Full support for seamless integration into your organization. Partner Success Support: Dedicated success manager for ongoing assistance and optimization. Custom Reporting: Regular insights and outcomes tracking for organizational transparency. Terms and Conditions: Fees are billed annually upfront. Services are provided for the agreed client capacity within the year. Additional client capacity can be purchased mid-year at prorated rates. Renewals occur automatically unless canceled with 30 days’ written notice before the term’s end.

$100,000.00 for each year

Coverage for up to 1000 clients annually Product Image

Coverage for up to 1000 clients annuallyComprehensive Client Care: Evaluation, diagnosis, treatment, and ongoing management for each enrolled client. Technology Tools: Telehealth access, symptom tracking, and automated care solutions. Onboarding & Training: Full support for seamless integration into your organization. Partner Success Support: Dedicated success manager for ongoing assistance and optimization. Custom Reporting: Regular insights and outcomes tracking for organizational transparency. Terms and Conditions: Fees are billed annually upfront. Services are provided for the agreed client capacity within the year. Additional client capacity can be purchased mid-year at prorated rates. Renewals occur automatically unless canceled with 30 days’ written notice before the term’s end.

$999,999.00 for each year

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Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Signature*

AutoPsych Partnership Purchase Agreement