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Purchase Order Psychologist in United States San Francisco –Free Word Template Download with AI

Bay Area Wellness & Behavioral Health Services, Inc.

1200 Market Street, Suite 4500, United States San Francisco, CA 94102

Phone: (415) 555-0187 | Email: [email protected]

PO Number: PO-2025-SF-04872

Date of Issue: June 12, 2025 | Valid Until: September 12, 2025

Vendor / Service Provider

Dr. Elena M. Vasquez, Ph.D., Licensed Psychologist

Golden Gate Psychological Associates

2847 Fillmore Street, Suite 310

United States San Francisco, CA 94115

CA License No.: PSY-184729

Tax ID (EIN): 94-2837461

Receiving Department

Corporate Employee Assistance Program (EAP)

Bay Area Wellness & Behavioral Health Services, Inc.

Attn: Marcus T. Chen, Director of Procurement

1200 Market Street, Suite 4500

United States San Francisco, CA 94102

Item # Description of Psychologist Services Qty Unit Unit Price (USD) Extended Price (USD)
1 Individual clinical therapy sessions (50 min) – Licensed Psychologist, Dr. Vasquez – for EAP-registered employees in the United States San Francisco metropolitan area 240 Session $225.00 $54,000.00
2 Group psychological counseling workshops (2-hour sessions) – Psychologist-led stress management and resilience training for corporate teams 12 Workshop $1,800.00 $21,600.00
3 Psychological assessment and diagnostic evaluation – Comprehensive battery administered by the Psychologist for pre-employment and annual wellness screening 60 Assessment $450.00 $27,000.00
4 Crisis intervention and emergency psychological support – On-call Psychologist availability (24/7) for acute mental health incidents at the United States San Francisco office 1 Annual Contract $18,500.00 $18,500.00
5 Monthly progress reporting and compliance documentation – Psychologist to submit confidential aggregate reports to the EAP director 12 Month $350.00 $4,200.00

Subtotal: $125,300.00

Applicable Sales Tax (CA – 8.25%): $10,337.25

Administrative Fee (2%): $2,506.00

Grand Total: $138,143.25 USD

Terms and Conditions of This Purchase Order

  1. Scope of Services: This Purchase Order authorizes the engagement of Dr. Elena M. Vasquez, a Licensed Psychologist, to deliver the professional psychological services itemized above. All services shall be rendered in compliance with the California Board of Psychology regulations and applicable federal mental health privacy laws, including HIPAA.
  2. Service Location: All in-person sessions, workshops, and assessments shall take place at the vendor's office located in United States San Francisco, CA 94115, or at the client's premises at 1200 Market Street, United States San Francisco, CA 94102, as mutually agreed upon in writing prior to scheduling.
  3. Payment Terms: Net 30 days from the date of invoice. Payment shall be made via ACH transfer to the account designated by the Psychologist. Late payments shall accrue interest at 1.5% per month as permitted under California Commercial Code Section 2210.25.
  4. Confidentiality: The Psychologist shall maintain strict confidentiality of all client records in accordance with 42 CFR Part 2, the California Confidentiality of Medical Information Act (CMIA), and the terms of this Purchase Order. No individual client data shall be disclosed to the purchasing entity without written consent.
  5. Licensing and Insurance: The Psychologist warrants that she holds an active, unrestricted license to practice psychology in the State of California (License No. PSY-184729) and maintains professional liability insurance with a minimum coverage of $2,000,000 per occurrence. A certificate of insurance shall be provided upon request.
  6. Termination: Either party may terminate this Purchase Order with 30 days' written notice. Services already rendered and documented prior to the termination date shall be invoiced and paid in full.
  7. Governing Law: This Purchase Order shall be governed by and construed in accordance with the laws of the State of California. Any disputes arising hereunder shall be subject to the exclusive jurisdiction of the state or federal courts located in San Francisco County, United States San Francisco.
  8. Non-Assignment: The Psychologist shall not assign, subcontract, or delegate any portion of the services described in this Purchase Order to any third party without the prior written consent of the purchasing entity.
  9. Compliance: The Psychologist agrees to comply with all applicable federal, state, and local laws and regulations in the performance of services under this Purchase Order, including but not limited to the Americans with Disabilities Act (ADA) and California Fair Employment and Housing Act (FEHA).

Authorized by (Purchasing Entity):

Marcus T. Chen
Director of Procurement
Bay Area Wellness & Behavioral Health Services, Inc.
Date: _______________

Accepted by (Psychologist / Vendor):

Dr. Elena M. Vasquez, Ph.D.
Licensed Psychologist
Golden Gate Psychological Associates
Date: _______________

This Purchase Order (PO-2025-SF-04872) is a binding document between Bay Area Wellness & Behavioral Health Services, Inc. and Dr. Elena M. Vasquez, Licensed Psychologist, for the provision of professional psychological services in United States San Francisco, California. This document is valid only when signed by both parties. For questions regarding this Purchase Order, contact the Procurement Department at (415) 555-0187.

© 2025 Bay Area Wellness & Behavioral Health Services, Inc. All rights reserved. Document generated in United States San Francisco, CA.

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