Appointment failures or late cancellations (less than 24 hours in advance) will result in a $100.00 fee per occurence. Insurance companies will not cover charges for appointment failures or late cancellations.
If there are more than three no show or late canellations, clients may be terminated with alternative referrals provided. No show and late cancellations are defined as follows: if the client does not show (no effort was made by the client to contact the clinician) for their scheduled appointment or gives the therapist less than a 24 hour notice that they will be unable to attend their scheduled appointment time. Referrals can be provided via email, phone message, or in written form.
Should a client not accept these terms, they will be provided with an alternative referral.
My signature below indicated that I agree to the terms set by this policy.
I have read this form and it has been explained to me. I have been given an opporunity to ask questions about them and my questions have been answered.