Client Policy Agreement Form

Client Policy Agreement Form

Please review and acknowledge our policies by checking the boxes, signing, and dating below. Complete both sections as required.
Child/Client Name

First NameLast Name
Policy Acknowledgment - Section 1

Please read each statement and confirm your agreement.
I have read and agree to the Privacy Policy.
I have read and agree to the Terms of Service.
Signature (Section 1)
Name of Parent/Representative signing
Date (Section 1)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Acknowledgment - Section 2

Please review any additional policies and confirm your agreement.
I have read and agree to the Refund Policy.
I have read and agree to the Code of Conduct.
I acknowledge and agree to the following terms:
1. I understand that Hope and Inspiration Psychological Services requires a credit card on file prior to scheduling for accounts covered by commercial insurance (such as BCBS or Aetna).
2. I understand that commercial insurance coverage is subject to deductibles and copays, and I am financially responsible for any balance not covered by my insurance policy.
3. Medicaid Disclaimer: I understand that clients with active Medicaid coverage will not be charged for Medicaid-covered services.
4. I authorize Hope and Inspiration Psychological Services to process required deposits and remaining commercial insurance balances using the designated payment method on file.
Please check the box to agree to the statement above:
Signature (Section 2)
Name of Parent/Representative signing
Date (Section 2)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Client Policy Agreement Form

Policy Acknowledgment - Section 1

Policy Acknowledgment - Section 2