For clients utilizing their insurance coverage as a method of payment, please note, in the event that the claims in rejected by your insurance, the client will be responsible for the full amount charged for the therapy session.
Rates for the therapy session vary based on the insurance provider.
For details about the full amount charged based on the insurance provider; consult directly with the therapist and/or your insurance provider.
Full payment will be due within 30 days from the written notification of the rejected claims.
No other sessions will be held until the full payment is received.
By signing this document, the client is under the understanding and agreement that their insurance provider may reject payment for the therapy session. In those cases, the client will take financial ownership of the bill due.
Thank you for your consideration regarding this important matter.
Client Signature (Client’s Parent/Guardian if under 18)
