Updated Financial Appeal Form

1
Your Name
First Name
Last Name
2
Your Email
example@example.com
3
Client's Name
First Name
Last Name
4
Clinician's Name
Please Select
Please Select
Miles Keller
Beth Morris
Abby Fedewa
Danielle Piggott
Brinna Lee
Sydney Friend
Connor Jewell
Stephanie Germain
Brian Leidal
ReBecca Wilcox
Shelly Campbell
Allie Valentino
Caytlin Schultz
Lauren Valdez
Julia Sant
Kelly Mack
Michael Ohonbamu
Hannah Battles
Caitlin Byers
Quinnay Hones
Nicole Vergeldedios
Chris Dinh
Amanda Frazier
5
Email
example@example.com
6
Today's Date
Date
Year
Month
Day
7
I am requesting an appeal for the following:
Late Cancellation/Missed Appointment Fee
Pause of Services due to Nonpayment
Other
8
I reviewed and signed the informed consent when services began at Timber Creek Counseling.
Yes
No
9
Please describe why you are requesting an appeal.Please note that appeals are only granted for extenuating circumstances and are at the discretion of Timber Creek's Administrative team.
Huge
Large
Normal
Small
Ok
Ok
10
SignatureI attest that the information above is correct, to the best of my knowledge and that filling out this request is not a guarantee my request will be granted.
Clear
Should be Empty: