Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Pricing Packages *

Individual Therapy Session Rate (Face-to-Face/Online) = $199

Four (4) Session Plan @ $149 x 4 = $596 (Save $200)

Eight (8) Session Plan @ $119 x 8 = $952 (Save $640)

Fees *

I, the client, understand and accept that… 1. Single Session @ $199 (45 minute Session) = $199 Four (4) Session Plan @ $149 (45 minute Session) x 4 = $596 (Save $200) Eight (8) Session Plan @ $119 (45 minute Session) x 8 = $952 (Save $640) 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.

I confirm that I have read, understood and agree with the above.

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.

I confirm that I have read, understood and agree with the above.

Refund Policy *

I, the client, understand and accept that… 1. There are no refunds once services have been rendered

I confirm that I have read, understood and agree with the above.

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.

I confirm that I have read, understood and agree with these terms.

Today's Date *

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DD

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