New Client Financial Agreement

 
Name *
Name
Address
Address
Phone *
Phone
Pricing Packages *
Fees *
I, the client, understand and accept that… 1. Single Session Rate (office visit) @ $119 x One (1) forty-five (45) minute session = $119 Single Session Rate (online/remote) @ $79 x One (1) forty-five (45) minute session = $79 2. There is a service fee of $3 for each therapy session. 3. Payment must be made in advance of all scheduled therapy sessions. 4. Payment must be made online using a credit or debit card.
Cancelation and Rescheduling *
I, the client, understand and accept that… 1. If I need to reschedule/cancel a therapy session, I must provide at least 24-hours’ notice. 2. If I fail to provide at least 24-hours’ notice, I will be charged the full session fee.
Refund Policy *
I, the client, understand and accept that… 1. There are no refunds once services have been rendered
Terms *
As a therapy client, I understand and agree that I am completely responsible for my well-being during my time in therapy. This includes my choices and decisions. No guarantees have been made to me as to the expected outcome of my therapy. I am aware that I can choose to discontinue therapy at any time.
Today's Date *
Today's Date