Common use of Important Policies Clause in Contracts

Important Policies. ➢ I accept for payment all major credit cards, cash, bank cards and most Health Saving Accounts. ➢ If you must reschedule or cancel an appointment, 24-hours notice is required. This is because the time slot is reserved for you and time is spent preparing for your session. Cancellations without 24-hours notice will be charged $75. I understand there are times when unforeseen emergencies arise and these will be determined case by case. Hospitalizations and deaths in the immediate family are not billed. Bishops or insurance companies do not cover cancellation fees. This will be your responsibility. ➢ It is your responsibility to contact the therapist and let them know if you are unable to make your appointment and why. A credit card number is required to hold on file. This card will be charged by the end of the working day the cancellation fee. Prior to the charge, an attempt will be made to notify you. This information is stored in a secure location. You do not have to use this card as payment for sessions and can use any form of payment you prefer. ➢ Payment is expected at the beginning of each session. No late payments will be accepted. ➢ You are welcome to come late to your session and use the remaining time available yet the session will need to end at the scheduled appointment time. You will be charged the full amount for the appointment excluding emergencies that will be determined on a case to case basis. If you are more than 15 minutes late for your session it will be considered a missed session and you will be charged the full session fee. It is expected that you will call and notify your therapist if you are running late. ➢ If you need to speak with me between sessions, I will respond as promptly as possible. I may be unavailable due to being in sessions but will respond within 24-48 hours. Unless, you have signed an agreement to participate in phone therapy and have reviewed the risks, phone calls are not intended for therapy. Please address your questions and concerns in your next session. Phone calls lasting longer than 10 minutes will be charged a pro-rated fee of $10 per additional minute. (I may phone parents with an update. The first 10 minutes are free. If the call continues past this point then on minute 11= $110, 12 minutes =$120). ➢ Time spent completing requests for additional documentation/paperwork outside of the standard amount will be charged $65 per 15 minutes. ➢ In the event that a client has three no show/cancellations in a row the therapist will begin the termination process. At this point, the client will not be permitted to schedule future appointments. However, if the client still desires to have services then the client may call the morning of and schedule a same day appointment if one is available. ➢ Failure to pay for services will lead to termination of treatment until the full balance is paid. Clients working with Ecclesiastical leaders are required to submit their bill to their leader. A balance of over $800 will require the bill to be paid before treatment can progress. Also, I may turn over delinquent accounts to a collection agency, and you may be responsible for collection and attorney fees. Every effort to contact you will be made prior to taking any action. ➢ You will be provided 30 days notice of any policy changes, including fee increases. ➢ You understand that you are responsible for the fees and cancellation fees as outlined above. In the event that your ecclesiastical leader or insurance do not pay, you are taking full responsibility for the bill. Fees Code Services Licensed Professional Associate/Xxxxxx Pay 90791 Intake Session (60 Minutes) $185 $160 90834 Individual/Family Therapy 45 Minutes $125 $100 90837 Individual/Family Therapy/Couples 60 Minutes $165 $140 Couple Session 75 Minutes $208 $183 90853 Group Session $45 $45 90839 Crisis Session 60 Minutes $175 $150 Neurofeedback 45 Minute Session $100 or (10 Pack for $650)* $100 or (10 Pack for $650)* Self-Care Pack Ten (45 Minute Sessions) $850* $750* Self-Care + Therapy 20 (45 Minute Sessions) 2x week $1800* $1550* Class Hold Me Tight Class $50 per couple per session $50 per couple per session * All packages are prepaid and non-refundable. ** There is no sliding scale available. A few scholarship spots are available providing a slight reduction in fees based on availability and need. These are provided on a first come first serve basis and a client may request to be placed on a wait list for the next available spot. There is no guarantee that a spot will come available. CREDIT CARD AUTHORIZATION I understand Achieve Family Therapy follows the Payment Card Industry Data Security Standard (PCI DSS) set of requirements designed to ensure that all companies that process, store, or transmit credit card information maintain a secure environment for financial data. Credit card number Exp: CCV code: Name on card: Zip Code (if different from prior listed): I understand that if I fail to make payments owed for attended sessions, if I do not attend a scheduled session, or if I cancel a session less than 24 hours from the start time of the session, and do not make the required payment(s) within 1 business days, Achieve Family Therapy, PLLC has my permission to charge the card listed above according to the Cancellation Policy/No-Show Policy. I understand that if I am having difficulty paying I can speak with my therapist about alternative arrangements. By signing this financial agreement form, I acknowledge that I have read, fully understand, and agree to the policies and terms contained herein. Client Signature Date

Important Policies. ➢ ⮚ I accept for payment all major credit cards, cash, bank cards and most Health Saving Accounts. ➢ ⮚ If you must reschedule or cancel an appointment, 24-hours notice is required. This is because the time slot is reserved for you and time is spent preparing for your session. Cancellations without 24-hours notice will be charged $75. I understand there are times when unforeseen emergencies arise and these will be determined case by case. Hospitalizations and deaths in the immediate family are not billed. Bishops or insurance companies do not cover cancellation fees. This will be your responsibility. ➢ ⮚ It is your responsibility to contact the therapist and let them know if you are unable to make your appointment and why. A credit card number is required to hold on file. This card will be charged by the end of the working day the cancellation fee. Prior to the charge, an attempt will be made to notify you. This information is stored in a secure location. You do not have to use this card as payment for sessions and can use any form of payment you prefer. ➢ ⮚ Payment is expected at the beginning of each session. No late payments will be accepted. ➢ ⮚ You are welcome to come late to your session and use the remaining time available yet the session will need to end at the scheduled appointment time. You will be charged the full amount for the appointment excluding emergencies that will be determined on a case to case basis. If you are more than 15 minutes late for your session it will be considered a missed session and you will be charged the full session fee. It is expected that you will call and notify your therapist if you are running late. ➢ ⮚ If you need to speak with me between sessions, I will respond as promptly as possible. I may be unavailable due to being in sessions but will respond within 24-48 hours. Unless, you have signed an agreement to participate in phone therapy and have reviewed the risks, phone calls are not intended for therapy. Please address your questions and concerns in your next session. Phone calls lasting longer than 10 minutes will be charged a pro-rated fee of $10 per additional minute. (I may phone parents with an update. The first 10 minutes are free. If the call continues past this point then on minute 11= $110, 12 minutes =$120). ➢ ⮚ Time spent completing requests for additional documentation/paperwork outside of the standard amount will be charged $65 per 15 minutes. ➢ ⮚ In the event that a client has three no show/cancellations in a row the therapist will begin the termination process. At this point, the client will not be permitted to schedule future appointments. However, if the client still desires to have services then the client may call the morning of and schedule a same day appointment if one is available. ➢ ⮚ Failure to pay for services will lead to termination of treatment until the full balance is paid. Clients working with Ecclesiastical leaders are required to submit their bill to their leader. A balance of over $800 will require the bill to be paid before treatment can progress. Also, I may turn over delinquent accounts to a collection agency, and you may be responsible for collection and attorney fees. Every effort to contact you will be made prior to taking any action. ➢ ⮚ You will be provided 30 days notice of any policy changes, including fee increases. ➢ ⮚ You understand that you are responsible for the fees and cancellation fees as outlined above. In the event that your ecclesiastical leader or insurance do not pay, you are taking full responsibility for the bill. Fees Code Services Licensed Professional Associate/Xxxxxx Pay 90791 Intake Session (60 Minutes) $185 $160 145 90834 Individual/Family Therapy 45 Minutes $125 $100 90837 Individual/Family Therapy/Couples 60 Minutes $165 $140 Couple Session 75 Minutes $208 $183 167 90853 Group Session $45 $45 90839 Crisis Session 60 Minutes $175 $150 Neurofeedback 45 Minute 145 90840 Crisis Session $100 or add on (10 Pack for $650)* $100 or (10 Pack for $650)* Self-Care Pack Ten (45 Minute Sessions30 min add on to 90839 above) $850* 67.50 $750* Self-Care + Therapy 20 (45 Minute Sessions) 2x week $1800* $1550* Class 50 Hold Me Tight Class $50 per couple per session $50 per couple per session * All packages are prepaid and non-refundable. ** There is no sliding scale available. A few scholarship spots are available providing a slight reduction in fees based on availability and need. These are provided on a first come first serve basis and a client may request to be placed on a wait list for the next available spot. There is no guarantee that a spot will come available. CREDIT CARD AUTHORIZATION I understand Achieve Family Therapy follows the Payment Card Industry Data Security Standard (PCI DSS) set of requirements designed to ensure that all companies that process, store, or transmit credit card information maintain a secure environment for financial data. Credit card number Exp: CCV code: Name on card: Zip Code (if different from prior listed): I understand that if I fail to make payments owed for attended sessions, if I do not attend a scheduled session, or if I cancel a session less than 24 hours from the start time of the session, and do not make the required payment(s) within 1 business days, Achieve Family Therapy, PLLC has my permission to charge the card listed above according to the Cancellation Policy/No-Show Policy. I understand that if I am having difficulty paying I can speak with my therapist about alternative arrangements. By signing this financial agreement form, I acknowledge that I have read, fully understand, and agree to the policies and terms contained herein. Client Signature Date

Important Policies. ➢  I accept for payment all major credit cards, cash, bank cards and most Health Saving Accounts. ➢  If you must reschedule or cancel an appointment, 24-hours notice is required. This is because the time slot is reserved for you and time is spent preparing for your session. Cancellations without 24-hours notice will be charged $75. I understand there are times when unforeseen emergencies arise and these will be determined case by case. Hospitalizations and deaths in the immediate family are not billed. Bishops or insurance companies do not cover cancellation fees. This will be your responsibility. ➢  It is your responsibility to contact the therapist and let them know if you are unable to make your appointment and why. A credit card number is required to hold on file. This card will be charged by the end of the working day the cancellation fee. Prior to the charge, an attempt will be made to notify you. This information is stored in a secure location. You do not have to use this card as payment for sessions and can use any form of payment you prefer. ➢  Payment is expected at the beginning of each session. No late payments will be accepted. ➢  You are welcome to come late to your session and use the remaining time available yet the session will need to end at the scheduled appointment time. You will be charged the full amount for the appointment excluding emergencies that will be determined on a case to case basis. If you are more than 15 minutes late for your session it will be considered a missed session and you will be charged the full session fee. It is expected that you will call and notify your therapist if you are running late. ➢  If you need to speak with me between sessions, I will respond as promptly as possible. I may be unavailable due to being in sessions but will respond within 24-48 hours. Unless, you have signed an agreement to participate in phone therapy and have reviewed the risks, phone calls are not intended for therapy. Please address your questions and concerns in your next session. Phone calls lasting longer than 10 minutes will be charged a pro-rated fee of $10 per additional minute. (I may phone parents with an update. The first 10 minutes are free. If the call continues past this point then on minute 11= $110, 12 minutes =$120). ➢  Time spent completing requests for additional documentation/paperwork outside of the standard amount will be charged $65 per 15 minutes. ➢  In the event that a client has three no show/cancellations in a row the therapist will begin the termination process. At this point, the client will not be permitted to schedule future appointments. However, if the client still desires to have services then the client may call the morning of and schedule a same day appointment if one is available. ➢  Failure to pay for services will lead to termination of treatment until the full balance is paid. Clients working with Ecclesiastical leaders are required to submit their bill to their leader. A balance of over $800 will require the bill to be paid before treatment can progress. Also, I may turn over delinquent accounts to a collection agency, and you may be responsible for collection and attorney fees. Every effort to contact you will be made prior to taking any action. ➢  You will be provided 30 days notice of any policy changes, including fee increases. ➢  You understand that you are responsible for the fees and cancellation fees as outlined above. In the event that your ecclesiastical leader or insurance do not pay, you are taking full responsibility for the bill. Fees Code Services Licensed Professional Associate/Xxxxxx Pay 90791 Intake Session (60 Minutes) $185 175 $160 135 90834 Individual/Family Therapy 45 Minutes $125 $100 90837 Individual/Family Therapy/Couples 60 Minutes $165 $140 Couple Out of Pocket- 35-minute session NeurOptimal Session 75 Minutes $208 100 a session with a Technician $183 550 prepaid package of 10 sessions 90853 Group Session $45 $45 90839 Crisis Session 60 Minutes $175 $150 Neurofeedback 45 Minute 145 90840 Crisis Session $100 or add on (10 Pack for $650)* $100 or (10 Pack for $650)* Self-Care Pack Ten (45 Minute Sessions30 min add on to 90839 above) $850* 67.50 $750* Self-Care + Therapy 20 (45 Minute Sessions) 2x week $1800* $1550* Class 50 Hold Me Tight Class $50 per couple per session $50 per couple per session * All packages are prepaid and non-refundable. ** There is no sliding scale available. A few scholarship spots are available providing a slight reduction in fees based on availability and need. These are provided on a first come first serve basis and a client may request to be placed on a wait list for the next available spot. There is no guarantee that a spot will come available. CREDIT CARD AUTHORIZATION I understand Achieve Family Therapy follows the Payment Card Industry Data Security Standard (PCI DSS) set of requirements designed to ensure that all companies that process, store, or transmit credit card information maintain a secure environment for financial data. Credit card number Exp: CCV code: Name on card: Zip Code (if different from prior listed): I understand that if I fail to make payments owed for attended sessions, if I do not attend a scheduled session, or if I cancel a session less than 24 hours from the start time of the session, and do not make the required payment(s) within 1 business days, Achieve Family Therapy, PLLC has my permission to charge the card listed above according to the Cancellation Policy/No-Show Policy. I understand that if I am having difficulty paying I can speak with my therapist about alternative arrangements. By signing this financial agreement form, I acknowledge that I have read, fully understand, and agree to the policies and terms contained herein. Client Signature Date

Important Policies. ➢ ⮚ I accept for payment all major credit cards, cash, bank cards and most Health Saving Accounts. ➢ ⮚ If you must reschedule or cancel an appointment, 24-hours notice is required. This is because the time slot is reserved for you and time is spent preparing for your session. Cancellations without 24-hours notice will be charged $75. I understand there are times when unforeseen emergencies arise and these will be determined case by case. Hospitalizations and deaths in the immediate family are not billed. Bishops or insurance companies do not cover cancellation fees. This will be your responsibility. ➢ ⮚ It is your responsibility to contact the therapist and let them know if you are unable to make your appointment and why. A credit card number is required to hold on file. This card will be charged by the end of the working day the cancellation fee. Prior to the charge, an attempt will be made to notify you. This information is stored in a secure location. You do not have to use this card as payment for sessions and can use any form of payment you prefer. ➢ ⮚ Payment is expected at the beginning of each session. No late payments will be accepted. ➢ ⮚ You are welcome to come late to your session and use the remaining time available yet the session will need to end at the scheduled appointment time. You will be charged the full amount for the appointment excluding emergencies that will be determined on a case to case basis. If you are more than 15 minutes late for your session it will be considered a missed session and you will be charged the full session fee. It is expected that you will call and notify your therapist if you are running late. ➢ ⮚ If you need to speak with me between sessions, I will respond as promptly as possible. I may be unavailable due to being in sessions but will respond within 24-48 hours. Unless, you have signed an agreement to participate in phone therapy and have reviewed the risks, phone calls are not intended for therapy. Please address your questions and concerns in your next session. Phone calls lasting longer than 10 minutes will be charged a pro-rated fee of $10 per additional minute. (I may phone parents with an update. The first 10 minutes are free. If the call continues past this point then on minute 11= $110, 12 minutes =$120). ➢ ⮚ Time spent completing requests for additional documentation/paperwork paperwork/billing/legal proceedings (outside of the standard amount for billing insurance initially without client errors) will be charged $65 per 15 minutes. ➢ ⮚ In the event that a client has three no show/cancellations in a row the therapist will begin the termination process. At this point, the client will not be permitted to schedule future appointments. However, if the client still desires to have services then the client may call the morning of and schedule a same day appointment if one is available. ➢ ⮚ Failure to pay for services will lead to termination of treatment until the full balance is paid. Clients working with Ecclesiastical leaders are required to submit their bill to their leader. A balance of over $800 will require the bill to be paid before treatment can progress. Also, I may turn over delinquent accounts to a collection agency, and you may be responsible for collection and attorney fees. Every effort to contact you will be made prior to taking any action. ➢ ⮚ You will be provided 30 days notice of any policy changes, including fee increases. ➢ ⮚ You understand that you are responsible for the fees and cancellation fees as outlined above. In the event that your ecclesiastical leader or insurance do not pay, you are taking full responsibility for the bill. Fees Code Services Licensed Professional Associate/Xxxxxx Pay 90791 Intake Session (60 Minutes) $185 215 $160 180 90834 Individual/Family Individual Therapy 45 Minutes $125 155** $100 120** 90837 Individual/Family Therapy/Couples 60 53 Minutes $165 195** $140 Couple 160** Out of Pocket- 45-minute session NeurOptimal Session 75 Minutes $208 100 a session with a technician or 10 pack for $183 750 * $750* prepaid package of 10 sessions Out of Pocket Self-Care Pack Ten (55 Minute Sessions with NeurOptimal) $1050 * $1050* Self-Care plus Therapy 20 (45 Minute Sessions) 2x week $2050* $1770 * 90853 Group Session $45 $45 90839 Crisis Session 60 Minutes $175 215 $150 Neurofeedback 45 Minute 180 90840 Crisis Session $100 or add on (10 Pack for $650)* $100 or (10 Pack for $650)* Self-Care Pack Ten (45 Minute Sessions30 min add on to 90839 above) $850* 97.50 $750* Self-Care + 80 90832 Individual Therapy 20 (45 Minute Sessions) 2x week 30 Minutes $1800* 97.50 $1550* Class 80 Hold Me Tight Class $50 per couple per session 440 Total for the Class $50 per couple per session 440 Total for the Class * All packages are prepaid and non-refundable. *refundable * There is no sliding scale available. A few scholarship spots are available providing a slight reduction in fees based on availability and need. These are provided on a first come first serve basis and a client may request to be placed on a wait list for the next available spot. There is no guarantee that a spot will come available. **For Private Pay Clients only: Those clients who are committed to coming in every other week or weekly may qualify for a discounted rate. Those who choose to prepay for 2 sessions in advance may receive a 5% discount, for 5 sessions in advance may receive a 10% discount and for those clients prepaying 10 sessions in advance will receive a 15% discount off the posted rate for their commitment to therapy. All prepaid sessions are nonrefundable. There will be, no more than two sessions, rescheduled in that time frame. For example, a client paying for 10 sessions in advance may only reschedule up to 2 sessions during the 10-week period. CREDIT CARD AUTHORIZATION I understand Achieve Family Therapy follows the Payment Card Industry Data Security Standard (PCI DSS) set of requirements designed to ensure that all companies that process, store, or transmit credit card information maintain a secure environment for financial data. Credit card number Exp: CCV code: Name on card: Zip Code (if different from prior listed): I understand that if I fail to make payments owed for attended sessions, if I do not attend a scheduled session, or if I cancel a session less than 24 hours from the start time of the session, and do not make the required payment(s) within 1 business days, Achieve Family Therapy, PLLC has my permission to charge the card listed above according to the Cancellation Policy/No-Show Policy. I understand that if I am having difficulty paying I can speak with my therapist about alternative arrangements. By signing this financial agreement form, I acknowledge that I have read, fully understand, and agree to the policies and terms contained herein. Client Signature DateDate Xxxxxxxx Xxxxxxx, MA, LMFT, CEFT Date Xxxxxxx Xxxxx, MS, LMHC