Upon verification of your health plan/insurance coverage and policy limits, your insurance carrier will be billed for your treatment, and your Therapist will be paid directly by the carrier. You will be responsible for any applicable deductibles and co - payments. If you are not eligible for insurance coverage at the time services are rendered, you will be responsible for the full payment. All payments are due at time of visit.

I understand that if I miss an appointment without 24-hour advance notice, other than in an emergency, I will be charged the full session fee of $__________________.

I understand that my therapist holds this time open for me and as part of my commitment to therapy, I will give my therapist the courtesy of a call so that he/she may schedule someone else if I cannot make the appointment. I also understand that my insurance company does not pay for no show appointments or appointments not cancelled within 24 hours.

________________________________ ___________________
(signature of patient) (date)

________________________________ ____________________
(signature of therapist) (date)

Revised April 14, 2003 Form 3