CREDIT CARD AUTHORIZATION FOR PSYCHOLOGICAL SERVICES RENDERED

For clients under 18 years old, name & relationship of person responsible for payment:

Please read and initial consent next to each section below:

 

TERMS

I authorize Daily DBT to keep my credit card on file for any future services until I request a cancellation. I will provide current card information at or before my first appointment. I understand that the terms of this authorization will remain in effect until I request that they be terminated. I acknowledge that I am responsible for making this request in writing.

RECURRING CHARGES

This recurring charge is to cover the cost of clinical services provided by Daily DBT.

$325 - Adult Initial Assessment (aka: Group Screening)

$110 - Adult group sessions

 

$350 - Adolescent Initial Assessment (aka: Group Screening)

$115 - Adolescent group sessions

$125 - Adolescent summer booster sessions

Individual skills training is charged at the rate of the individual therapist selected; I understand that this rate will be communicated to me and agreed upon prior to the utilization of any individual sessions.

ATTENDANCE / CANCELLATION POLICY

I understand that group is charged like tuition for a class and that this card will be charged for any and all missed sessions during the course of a module in accordance with the policies outlined in the Consent Form.

MONTHLY BILLING STATEMENTS

I understand that I will be emailed a monthly billing statement to the email address included in this contract unless I provide an alternate email address or request a different plan for billing statements.