No-Show & Late Cancellation Appeal Form
Garrett Counseling wants to increase our communities access to services. When a client fails to keep an appointment or cancels at the last minute, professional time goes unused and other clients fail to get timely service.

If we have made an error in scheduling or you believe you deserve special consideration for a “No-Show / Late Cancellation Fee”, please complete the following information. If you have additional information you want us to consider, please email supporting documents to billing@garrettcounseling.com. Your request will be reviewed and you will receive a decision via email.

This form must be completed no later than two weeks from the date of the missed appointment.

Sign in to Google to save your progress. Learn more
Client Full Legal Name *
Person Completing This Form *
Client Address *
Client Phone *
Client Email *
Date of Appointment Missed *
MM
/
DD
/
YYYY
Name of Counselor *
Describe the reason for requesting special consideration: *
Type full name in box for signature: *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Garrett Counseling.

Does this form look suspicious? Report

Google Forms