AGREEMENT TO PAY FOR PROFESSIONAL SERVICE

 

I, the undersigned, request that the above named therapist provide professional services to me/or as a client, and I agree to pay this therapist’s fee of $ for an initial evaluation and $ per session ( 45-50 60 90 minutes) for these services.

 

If the patient is a minor, I understand that while I have a right to general information on issues and progress, some information shared in this professional relationship will be held in confidence by the therapist and the minor child.

If, at any time, I am dissatisfied with this therapy I will fully discuss my views, reasons and plans with the therapist (and if the client is a minor, with the client named above) prior to terminating therapy.

I agree that this financial relationship will continue in effect with the above named professional as long as this therapist provides services or until I inform him or her, in person, by telephone or by certified mail, that I wish to end it. I agree to pay for services rendered to this patient up until the time I terminate the relationship.

I understand that I am responsible for charges for services provided by this therapist to me, although other persons or insurance companies may make payments on my account.

 

CANCELLATION OR NO-SHOW POLICY

I understand that I must cancel an appointment 24 hours in advance to avoid a cancellation fee. I will be charged half of my usual session fee if I cancel between 24 and 2 hours prior to my appointment. I will be charged the full session fee of if I cancel less than 2 hours prior to the session or if I fail to show up at all. The session fee is either the amount I self pay or the amount that the insurance company pays including my co-pay.

I agree to provide my credit card information at the time of intake and for my credit card to be charged the appropriate fee as indicated above in the event of a cancellation or no-show.

 

Full name:   DOB:   (MM/DD/YYYY)

 

Relationship to the patient: Self  Other:     Date:   (MM/DD/YYYY)

 

Home address:

 

I understand that by clicking the 'Submit Agreement to Pay Form' button below, I am responsible for charges for services provided by this therapist to me, although other persons or insurance companies may make payments on my account.