Client Agreement

Client Agreement

This document provides you with some brief information about what you can expect when using our counseling services. Please read carefully and sign below.
Payment Policies:
- We accept cash, checks, Visa, MasterCard, Discover or American Express for payment of sessions. Fees are due at the time services are rendered unless prior arrangements have been made. For payments that are made via credit card, the charges will be shown as “Faithful and True Ministries” and will be charged approximately 3-7 days after each session. Upon request, a receipt is available for your records.
- We are not a provider for any insurance company, we do not submit insurance claims, nor do we provide diagnostic coding for insurance purposes.
- You will be charged the full session fee for appointments that are not canceled at least 48 hours or two full business days in advance.
- If a client misses two appointments without canceling within these parameters or is non-compliant with our policies, Faithful and True reserves the right to discontinue services. If a client fails to attend a scheduled appointment, a credit card on file will be required in order for future appointments to be made.
Initial here to confirm that you have received a copy of our privacy policy and fee schedule. *
Email and Cell Phone Use: The use of email and cell phones to discuss therapeutic issues is not secure. While we would never share your email with anyone without your permission, email without encryption can be compromised. You agree that when you/I/we use email or cell phones, it will be under these conditions.

Our counselors are not “on-call” 24 hours so if you experience a life-threatening emergency, please call 911 or go to the nearest emergency room.
Name*

First NameLast Name
Signature*

Clear
Should be Empty: