Libratum Counseling, LLC

Financial Acceptance Form

I (Patient Name/Parent/Guardian) ________________________________________________, have read the statement below and agree by the terms and conditions.

We will make your payment as easy and convenient as possible. You may pay your copay or deductible by cash, check, credit card or debit card. We require a credit card on file to support the cancellation policy. (There is a 3% surcharge for every credit/debit card transaction)

Credit Card/Debit Card #: xxxx xxxx xxxx ________________ (Last 4 #’s) Exp. Date:

Card Type: Visa / MasterCard / Discover (circle one)

INITIAL: ______ I understand that a 24hr notice is needed for any cancellations or I will be billed the $40 fee:

This is not a billable charge to your insurance company. All cancellations need to be made by phone. I also understand that there will be a $25.00 charge for all returned checks.

I authorize Libratum Counseling, LLC to charge my co pay, outstanding balances and/or cancellation fee charged on my account to the provided credit card number/debit card or any replacement credit card that I supply during my treatment period. I also understand that any balance on my account ultimately becomes my responsibility as well as the primary insurance policy holders.

Signature_________________________________________________________   Date______________________________

Credit card information: (this section will be detached and destroyed once entered into our (PCI DSS) compliant system)

Credit/Debit Card # _________________________________________Expiration Date: ______/_______/________

Name on Card: ___________________________________Security Code: _________Billing Zip Code:________

Card Type: Visa / MasterCard / Discover (circle one)

Libratum Counseling, LLC

Cancellation Policy

Reason for this policy:

To be effective, counseling and psychotherapy need to take place on a regular basis. The best results occur when appointments are consistently scheduled and attended regularly. Additionally, an appointment time reserved for you means that it cannot be used for someone else. It is reserved for you and/or your family.

If the policy holder and/or patient does not notify the therapist by phone of your intention to cancel or reschedule 24hrs in advance, you will be charged the $40 fee:

Cancelling or re-scheduling within 24hrs allows the therapist an opportunity to schedule someone else for that time slot. This is important because others may be on a waiting list for or preferred your time slot.

If you reschedule to a later time of the day or week of your scheduled appointment and if there is an opening, the cancellation fee will be waived.

1)         You will never be charged for a cancellation that is made more than 24 hours in advance of your scheduled appointment time.

2)         This cancellation policy is standard in the mental health field.

3)         If you simply do not show up for a scheduled appointment, you will be charged for the missed appointment.

4)         This fee is not billable to your insurance company and is your out-of-pocket responsibility.

5)         Arriving late without notification: Your therapist will wait for you for 15 minutes after which they will assume you are not coming and may leave the office. In such a case, you will be charged for a missed appointment.

6)         On occasion, there will be understandable reasons for missing appointments, but, exceptions to this policy will be rare. In the event of illness or work emergency, a phone session is an option. There is no charge for missed appointments due to snow conditions or declared states of emergencies.

If you have questions about this cancellation policy, you should discuss this with your therapist at the start of therapy. Please sign below to indicate you have read, understand, and agree to abide by our cancellation policy. Thank you.

Signature:_________________________________________________ Date:_________________________________