NOTE: Italicized copy below appearing within brackets comprises notes and recommendations related to the sample will content.
I, . do hereby declare this to be my Professional Will. This document supersedes any prior Professional Will I may have created. This Professional Will is not a substitute for a Last Will and Testament or any document that I have executed or shall execute for the administration of my physical assets or my personal estate. It is intended solely to give authority and instructions to my Professional Executor regarding my psychotherapy practice and records in the event of my incapacity or death.
I am a practicing psychologist or therapist in
.
My license# is
.
My Licensing Board is
.
My principal office address is
.
In the event of my death or incapacity, I hereby appoint as my Professional Executor a representative of Dova
Professional Services LLC, (hereafter referred to as Dova) who has agreed to serve in this role.
Dova's phone
number and email are:
[email protected]
1-800-820-8210
I hereby grant to Dova authority to carry out any and all activities deemed
necessary to properly administer
this professional will including full authority to store, release or dispose of my professional records,
consistent with relevant laws, regulations and other professional requirements and to contact clients and
relevant others as provided below. See Limitations of Services below for limitations of Dova's obligations under
this document.
I designate the following individuals as the Responsible Party and alternate
Responsible Party to contact Dova in
the case of my incapacity or death. The contact information of Responsible Party and alternate are as
follows:
Name:
Phone:
Email:
Address:
Responsible party will be responsible for informing Dova of my death or incapacity using the contact
information
provided above.Dova will be under no obligation to act on my behalf until
it has been contacted and informed
by responsible party or alternate and has no responsibility to independently verify that I am in fact
incapacitated or deceased but will be free to act based solely on the report from my designated responsible
party.
Copies of a separate document called “Files, Passwords, and Contacts List” will be provided to Dova by my
Responsible Party concurrent with this Professional Will in the case of my incapacity or death. I agree to
maintain and update the document as needed so that the Responsible Party and Dova have access to all current
relevant contacts, client records and other relevant documents, including all electronic files. The list will
include:
Insert below the information that will be provided in the case of my incapacity or death.
My specific instructions for my Professional Executor are: There are three copies of this Professional Will. They are located as follows: one is in the possession of Dova Professional Services LLC, one is with my personal will; and one is
Dova's Professional Executor representative will utilize their clinical judgment and discretion in deciding how
to notify current clients of my death or incapacity and whom to contact for further information, consistent with
ethical and legal requirements.
If clinically indicated, for example by their response to notification
of my
death, the Professional Executor representative may wish to offer short-term telehealth support with some
clients.
The Professional Executor representative may also provide referrals sources for clients.
The
Professional Executor representative will promptly notify my professional liability carrier of my death.
The
Professional Executor representative will also notify my state licensing board.
The Professional
Executor
representative will arrange for clients' records or copies of their records to go to their new therapist or
other mental health professional, if applicable, with the clients' consent. All remaining records should be
maintained according to the relevant, most recent Ethics Standards, state regulations and Licensing board Record
Keeping Guidelines.
[Recommendation: Include in the informed consent document signed by clients at
the
onset of treatment a notification that if you die or become incapacitated, your Professional Executor may
take control of records and contact clients.]
Dova Professional Services LLC shall retain one
copy
of this Professional Executor Agreement. An additional copy should be securely stored with your personal will
documents, and a third copy must be held by a person or entity of your choice, as designated in writing by you.
I declare that the foregoing is true and correct.
Attached to this agreement and by this reference made part of it is
the
PROFESSIONAL EXECUTOR SERVICES AGREEMENT.
Signature:
Date:
Professional Executor Services Agreement
Professional Executor Agreement with Dova Professional Services LLC
By engaging Dova Professional Services LLC as my Professional Executor, I, the undersigned, acknowledge and agree to the following terms:
Representatives from Dova Professional Services are qualified Mental Health professionals who will use their clinical judgment to inform and support my clients in the event of my incapacitation or death. However, this support will be temporary, and appropriate referrals will be made promptly. All support will be provided remotely, either by telephone or through a secure telehealth platform. No in person support will be available.
Dova Professional Services will not engage in the management, liquidation, or handling of any physical aspects of a psychotherapy practice, including but not limited to ending leases, liquidating furniture, or collecting physical records and computer equipment. Dova Professional Services LLC and its representatives will not require access to any bank accounts or financial statements. Dova Professional Services LLC is not responsible for collecting any outstanding balances from clients or for managing any debts, fees, or other financial obligations of the undersigned or any related entities. Dova Professional Services LLC will not undertake any responsibilities related to the termination of the legal entity of the business or the closure of any bank accounts.
No demand for payment will be made by Dova Professional Services LLC or any of its representatives from my estate. All fees are payable monthly or annually, depending on the subscription plan chosen. The terms of this agreement are null and void if payments are not made as stipulated.
If I, choose to cancel my subscription at any time, this agreement will become null and void, and Dova Professional Services LLC will be released from all legal obligations under this Professional Executor Agreement.
Dova Professional Services LLC's obligations under this agreement are limited to notifying clients, providing support and referrals when clinically appropriate, and informing the relevant licensing boards and liability insurance providers, contingent upon the accuracy of the information provided by me. By signing below, I agree to the terms outlined in this Professional Executor Agreement with Dova Professional Services LLC.
Signature:
Date:
