Grace For All Families - Adult Counseling Form

Counseling Fee Sheet
(Please initial and date each statement.)
The current fee for counseling sessions is $90. The payment is due at the time of service. Grace For All Families counseling practice accepts the following as payment: cash, credit or debit card, or personal checks. Checks should be made payable to Grace For All Families. In the event of a returned check, the client should make every effort to pay for the session as soon as possible.
Signature*

Clear
Date*

MonthDayYear
Date
Checks should be made payable to Grace For All Families. In the event of a returned check, the client should make every effort to pay for the session as soon as possible.
Signature*

Clear
Date*

MonthDayYear
Date
Dr. Ransom has a 24-hour cancellation policy. Please be courteous: if you cannot keep the appointment, let me know so someone else can have it. Failure to cancel or reschedule within 24 hours of your appointment will result in a $20 office charge to be paid before the next visit, unless in case of emergency or otherwise discussed with Dr. Ransom. No-shows result in the forfeiture of services provided by Grace For All Families.
Signature*

Clear
Date*

MonthDayYear
Date

Family Info
Father's Name
Mother's Name
Name/Ages of Children (you may include stepchildren and children not in household):
Names/Ages of siblings (Please list in order of age):