Payment Policies and Authorization
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Clinician: *
Name of Person completing this form (as it appears on your Contact Form) *
                                          Payment and Cancellation
We accept credit cards, checks, and cash. We require a credit card authorization from you, even if you intend to pay by cash or check. We process credit card payments at the time of the appointment.

Our billing system is called Therapy Partner. Once we enter your Authorization Form into our billing system, you will receive an email from statements@therapypartner.com.  Please follow the instructions in the email to verify your email address and complete the verification process.  This will allow you to receive a secure billing statement automatically each month that a service has been rendered or obtain a statement at any time. Your card statement will reflect a charge from “Caring Couples, Happy Lives.” If you do not have access to the internet and prefer paper receipts, please let us know.

Please give us at least 24 hours’ notice if you must cancel your, or your partner's, appointment. If you cancel a session with less than 24 hours’ notice, arrive more than 15 minutes late for a session without notifying us, or do not show up for a session, you will be charged the fee for that session. You are responsible for full payment of fees incurred in the course of your work, including appointments for your partner.

                                                          Insurance
We do not guarantee or warrant that fees you pay will be covered by your insurer. If you would like to send receipts to your insurer, it will be necessary for a diagnosis to be included. Unless there is a bona fide mental health disorder that is the focus of treatment, the diagnosis that can be included on receipts is "Relationship Problem," which is generally not covered. We do not include a diagnosis on your receipt unless you specifically request one, you have completed a clinical assessment, and you have discussed it with your clinician in a face-to-face session.
                                                          Authorization
We require a unique credit card on file for each person in counseling. Please enter credit card information below that is for an account different from your partner's. You can designate which credit card, yours or your partner's, that you wish to use as a default card.
Account Holder Information
Full Name (as it appears on your card) *
Address (as it appears on your card) *
Street
City *
State *
Zip *
Phone Number (on file with credit card issuer) *
Email address (to which we can send receipts for your payment) *
Credit Card Information
Credit Card Type: *
Card Number: *
Security Code *
CVV
Expiration date - Month *
Expiration date - year *
By Clicking on Submit:
I affirm that I have read and agree to Caring Couples policies for payment, cancellation, and insurance. I affirm that I am legally entitled to authorize charges to the credit card accounted entered above. I authorize Caring Couples, Happy Lives to charge my credit card for services unless I have first paid by check or cash. I agree to pay the full amount incurred for services and to abide by my credit card issuer agreement.
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