Office Appointment Attendance Policy

Name of adult/guardian signing the form (if client is under 18) *

First Name Last Name

Client name if different from above

First Name Last Name

Email *

example@example.com

Phone Number *

Area Code Phone Number

Please carefully review and acknowledge each item *

At least a 24-hour notice is required to re-schedule your appointment. Requests for last minute re-scheduling disrupts the providers's availability and prevents others from taking your time slot. NO REFUNDS are given for no-shows or late cancellations (less than 24 hours). For the safety and comfort of all clients, please arrive on time. Arriving late means your session will be shortened. You may only bring a child to the appointment if this child is a client receiving direct services. Please make childcare arrangements (outside of the office) for young siblings who require adult supervision. During your appointment I request you silence your cell phone and refrain from making/receiving phone calls. This includes reading/responding to text message as you are actively in the session and in front of the practitioner. This happens once in a while and is very disruptive. Please wait until you are done with the appointment to check your phone (unless of course you are needing your phone to check your calendar and book next appointment). Due to COVID-19, you are asked to arrive wearing a mask and wear it for the entire duration of your appointment. I have an ultra HEPA Carbon and VOC filter cleaner running during all my client sessions to keep you safe. Use hand sanitizer upon the arrival provided by the office.

Signature

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Date Signed