Days that you are available: * Times that you are available: * In Person Virtual *
If you do not have insurance, you must agree to private payments (cash, check, debit card, etc.) for services. Private pay fees will be agreed upon with your therapist prior to the first session.Client Initials *
I have filled out the above information for the use of Brighter Health Counseling (hereafter known as BHC). I acknowledge that all information is correct and current. It is my responsibility to notify BHC of any changes to my address, insurance, or payment methods as soon as they become inaccurate or inactive.
I agree that BHC can release or obtain any medical information to my insurance company. I agree to allow BHC billing personnel to use paper & electronic billing methods with my insurance company. I understand that I am responsible for timely payments of fees from services provided by my therapist and/or BHC. I acknowledge that I am responsible for any outstanding balance and BHC reserves the right to forward my information to collections, and in addition a maximum of 30% may be assessed on my account to cover the costs of this action. There will be no obligation on BHC to provide continuing services to any client who names BHC as a creditor in any bankruptcy filing.
My signature below acknowledges that I have read, or someone has read the above information to me, and that I understand this information. I agree that if I have questions, the information has been explained and/or summarized for me.