Square Consent

Aware Mental Wellness uses Square, an online platform for scheduling client sessions and sending invoices.

What to Expect with Square

- You will receive an email and text notification upon your appointment being scheduled, canceled, or changed.

- Please confirm your appointment the day before and notify me via email, text, or voicemail if you can not make your scheduled session.

- Invoices for copays, deductibles, or full sessions will be sent via Square to your email on file. If you are paying out of pocket invoices must be paid prior to your next scheduled session. If you are using insurance and have a co-pay or deductible those invoices are sent twice a month. Lastly, if you have a late cancelation or no-show invoice, that will need to be paid before we meet again.

Acknowledgment

I have received this Square Consent Form and agree to its use for the scheduling and tracking of my psychotherapy appointments as well as billing as needed. As a reminder, my cancelation policy is 24 hours. Notice less than 24 hours in advance of your appointment will result in a charge for the FULL FEE (i.e., $120 or our agreed-upon fee), which will be billed directly to you, the client. Insurance will not pay for missed or canceled appointments. Payment will be expected by the next scheduled appointment unless we make other arrangements.

Client Name*

First NameLast Name

Email to be used with Square*

example@example.com

Phone Number to be used with Square*

Area CodePhone Number

For billing, please select one option below. This option can be changed at anytime by providing an updated form.*

I would like to be sent a new invoice as needed and pay onlineI will keep a card number on file with Square and consent to have it billed following each session or twice monthly (1st and 15th unless otherwise notified or agreed upon) by Emilie Moreau

Client or Parent/Guardian Signature*

Clear

Date Signed*

Date