PLEASE READ CAREFULLY: THIS IS A BINDING CONTRACT AUTHORIZATION FOR TREATMENT AND FINANCIAL AGREEMENT
Payment for professional services is due at the time the service is rendered.
I agree that I am financially responsible for all professional services rendered. If requested, our office will provide you an invoice you can file with your insurance.
A notice of 72 hours must be given for cancellation of an appointment.
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law.
I HEREBY AUTHORIZE AND CONSENT, BY MY SIGNATURE, TREATMENT OF THE ABOVE PERSON(S) AND CERTIFY, BY MY SIGNATURE, THAT I HAVE READ THE ABOVE, UNDERSTAND IT FULLY, AND AGREE TO THESE TERMS