Untimely Cancellation & No Show Policy Agreement
In order for our office to schedule your first appointment with LG Counseling, you are asked to please acknowledge that you have read, that you understand, and that you agree to our "Untimely Cancellation and No-Show Policy." By agreeing to this policy, we can proceed with scheduling your first session. You will also be asked to agree to this policy again in your new patient paperwork.
UNTIMELY CANCELLATION & NO-SHOW POLICY:
An “untimely cancellation” is when the patient / authorized representative fail to give at least 24-hours notice of cancellation of an appointment that is scheduled Tuesday THROUGH Saturday. If an appointment is scheduled on a Monday the patient / authorized representative must give notice by the previous Friday before 5pm that the appointment needs to be canceled in order to not be considered an “untimely cancellation.”
A “no show” is when the patient / authorized representative does not cancel nor attend the scheduled appointment with their provider.
Untimely cancellation / no show will result in a charge of $141.00. This charge is a separate fee and does not increase or decrease any other assessed fees. This fee applies to all patients. The patient / authorized representative will receive verbal and/or written notification of the charge for the missed appointment within same day of the previously scheduled appointment prior to charging the card on file unless the patient / authorized representative requests another form of payment to be used at the time notification is made. If the card on file declines, this fee is due before the patient's next appointment. Should the patient/ authorized representative choose to terminate the relationship, the fee is still owed.
Sessions may be canceled by contacting the office through phone or email. Leaving a voicemail counts as adequate notice provided it is made within the time constraints of this agreement.
BY SIGNING THIS FORM, THE PATIENT / AUTHORIZED REPRESENTATIVE UNDERSTANDS AND AGREES TO THE POLICY STATED ABOVE.