I hereby agree to the following fees and payment arrangement: $95.00 per therapy session payable at the time of the appointment or by other mutually agreed on schedule. I understand that this fee arrangement is between me and the service provider and that I will not be using my health insurance, if any, for this service. Furthermore, I will not be asking Matrix Health Systems to submit insurance claims.
I understand that 24 hours advance notice is required for cancellation of a scheduled appointment, and I agree to pay for any missed appointments or sessions canceled with less than 24 hours notice.