PLEASE READ CAREFULLY: I have read and understand the Disclosure Statement and Notice of Privacy Practices of Counseling West Seattle, and have had an opportunity to ask questions about them and have been given a copy of each for my records. With my consent my provider may contact me via email or text message, and I understand that these forms of communication are not HIPAA compliant. I agree to begin therapy with Counseling West Seattle for the disclosed fee, and to pay deductible and/or co-pay portions at the beginning of each session. I understand that if insurance does not cover the entire amount, I am responsible for the full cost of my treatment.
CANCELLATIONS: If I am unable to keep a scheduled appointment for any reason, I must notify my provider at least 24 hours in advance or I will be charged the full amount for the allotted time.
I am the parent/legal guardian of First Name Last Name and agree to the above terms on his/her behalf.I give permission for Counseling West Seattle to store my credit card on the secure platform, CardPointe.