Purchase Order Psychologist in United States New York City –Free Word Template Download with AI
Date of Issue: June 12, 2025
Valid Until: July 12, 2025
| Field | Details |
|---|---|
| Organization Name | Manhattan Behavioral Health Services, LLC |
| Address | 450 Lexington Avenue, Suite 1200, New York, NY 10017, United States New York City |
| Phone | (212) 555-0187 |
| [email protected] | |
| NYC Business License No. | NYC-BL-2024-88431 |
| Federal Tax ID (EIN) | 84-XXXXXXX |
| Field | Details |
|---|---|
| Professional Name | Dr. Elena M. Vasquez, Ph.D., Licensed Psychologist |
| Practice Name | Vasquez Psychological Consulting Group |
| Address | 210 West 42nd Street, Floor 8, New York, NY 10036, United States New York City |
| Phone | (646) 555-0342 |
| [email protected] | |
| NY State License No. | PSY-104829 (New York State Office of Professional Regulation) |
| NYC DOHMH Registration | NYC-DOHMH-2025-11204 |
| Federal Tax ID (EIN) | 91-XXXXXXX |
This Purchase Order is issued by Manhattan Behavioral Health Services, LLC for the engagement of a licensed Psychologist to provide clinical and consultative psychological services within the United States New York City metropolitan area. The Psychologist shall deliver all services in compliance with the New York State Education Law, the New York City Health Code, and all applicable federal regulations governing the practice of psychology.
| Line # | Service Description | Quantity | Unit | Unit Price (USD) | Total (USD) |
|---|---|---|---|---|---|
| 001 | Individual clinical psychology sessions (50-minute) conducted at the Psychologist's office in United States New York City, including intake assessment, diagnostic evaluation, and ongoing therapeutic treatment for adult clients referred by the Purchasing Entity. | 120 | Session | $225.00 | $27,000.00 |
| 002 | Group psychological counseling sessions (90-minute) for employee assistance program participants, facilitated by the Psychologist at the Purchasing Entity's Manhattan office in United States New York City. | 24 | Session | $450.00 | $10,800.00 |
| 003 | Comprehensive psychological assessment and written diagnostic report (including MMPI-3, WAIS-IV, and Rorschach administration) for pre-employment screening purposes, performed by the Psychologist. | 35 | Assessment | $650.00 | $22,750.00 |
| 004 | On-site crisis intervention and psychological first aid services provided by the Psychologist at any location within United States New York City upon 24-hour notice from the Purchasing Entity. | 6 | Engagement | $1,200.00 | $7,200.00 |
| 005 | Monthly clinical supervision and case consultation (4 hours per month) provided by the Psychologist to junior clinical staff of the Purchasing Entity, conducted via secure telehealth platform or in person in United States New York City. | 6 | Month | $800.00 | $4,800.00 |
| 006 | Written progress reports and clinical documentation submitted to the Purchasing Entity on a bi-weekly basis, prepared and signed by the Psychologist in accordance with HIPAA and New York State mental health record-keeping statutes. | 12 | Report | $150.00 | $1,800.00 |
| Subtotal | $74,350.00 | ||||
| New York City Sales Tax (Exempt – Professional Services) | $0.00 | ||||
| TOTAL PURCHASE ORDER AMOUNT | $74,350.00 | ||||
4.1 Scope of Services. The Psychologist identified in Section 2 of this Purchase Order shall perform all clinical, diagnostic, and consultative psychological services as described in Section 3. All services shall be rendered in the United States New York City or, where expressly authorized in writing by the Purchasing Entity, at an alternate location within New York State. The Psychologist shall maintain all required licensure, certifications, and malpractice insurance throughout the duration of this Purchase Order.
4.2 Payment Terms. The Purchasing Entity shall remit payment within thirty (30) calendar days of receipt of a valid invoice from the Psychologist. Invoices shall reference this Purchase Order number (PO-NYC-2025-04782) and shall be submitted to the accounts payable department at the address listed in Section 1. Late payments shall accrue interest at a rate of 1.5% per month as permitted under New York State commercial law.
4.3 Confidentiality and HIPAA Compliance. The Psychologist shall handle all client information in strict accordance with the Health Insurance Portability and Accountability Act (HIPAA), the New York State Mental Hygiene Law (Article 33), and all applicable privacy regulations in the United States New York City. No client records, session notes, or diagnostic data shall be disclosed to any third party without written client authorization or a valid court order.
4.4 Professional Standards. The Psychologist shall adhere to the ethical standards set forth by the American Psychological Association (APA) and the New York State Board for Psychology. Any violation of professional ethics shall constitute grounds for immediate termination of this Purchase Order without penalty to the Purchasing Entity.
4.5 Termination. Either party may terminate this Purchase Order with thirty (30) days written notice. The Purchasing Entity may terminate immediately for cause, including but not limited to loss of the Psychologist's New York State license, failure to maintain adequate malpractice insurance, or material breach of any term herein.
4.6 Governing Law. This Purchase Order shall be governed by and construed in accordance with the laws of the State of New York and the municipal ordinances of the United States New York City. Any disputes arising under this Purchase Order shall be resolved through binding arbitration in New York County, United States New York City, in accordance with the rules of the American Arbitration Association.
4.7 Insurance. The Psychologist shall maintain professional liability (malpractice) insurance with a minimum coverage of $2,000,000 per occurrence and $5,000,000 in the aggregate, naming the Purchasing Entity as an additional insured. A certificate of insurance shall be provided prior to the commencement of services.
By signing below, both parties acknowledge and agree to all terms, conditions, and service descriptions outlined in this Purchase Order. This document constitutes a binding agreement for the provision of psychological services in the United States New York City. For the Purchasing Entity:Manhattan Behavioral Health Services, LLC Name: Richard T. Calloway
Title: Director of Procurement & Vendor Management
Date: ______________________ For the Psychologist / Service Provider:
Vasquez Psychological Consulting Group Name: Dr. Elena M. Vasquez, Ph.D.
Title: Licensed Psychologist, Principal
Date: ______________________
This Purchase Order has been prepared in accordance with the internal procurement policies of Manhattan Behavioral Health Services, LLC and the regulatory requirements of the New York City Department of Health and Mental Hygiene (DOHMH). The Psychologist engaged under this Purchase Order is required to file an annual report with the New York State Office of Professional Regulation and to maintain a current practice location registered with the United States New York City Department of Consumer and Worker Protection. All services described herein are subject to the Psychologist's availability and the Purchasing Entity's client referral schedule. This Purchase Order does not create an employer-employee relationship; the Psychologist is engaged as an independent contractor for the duration of the services described.
— End of Purchase Order PO-NYC-2025-04782 —
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