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CLINICIAN-PATIENT AGREEMENT AND FINANCIAL RESPONSIBILITY

Fees:

Clients can pay by credit card, Zelle, or Paypal at the time of service. payment.

A 2.7% fee will be added when making a payment with a credit card.

There is a $25 late cancellation fee and if you don't show up for an appointment the full fee will be applied.

Emergencies:
The best phone number for all offices is 888-821-2935. If you receive the voice mail, please
leave a message for your personal counselor/coach.

Although I practiced for many years as a psychologist, I am not currently a licensed psychologist or specialist healthcare professional. My Life Coaching services do not replace the care of psychologists or other healthcare professionals.

Please note that I can’t take any responsibility for the results of your actions, and any harm or damage you suffer as a result of the use, or non-use of the information available . Please use judgment and conduct due diligence before taking any action or implementing any plan or practice suggested or recommended .

Also, please note that I don’t make any guarantees about the results of the information applied . I share educational and informational resources that are intended to help you succeed in . You nevertheless need to know that your ultimate success or failure will be the result of your own efforts, your particular situation, and innumerable other circumstances beyond my knowledge and control.

I have read, understand, and agree with the above policies. I can make a copy of these policies to
take with me if desired. I agree to accept financial responsibility for payment of charges
incurred.

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Signed by Jean Pollack
Signed On: October 24, 2023

Timestamp

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October 31, 2021 5:51 pm EST

Clinician-Patient Agreement and Financial Responsibility Uploaded by Jean Pollack - [email protected] IP 2600:4040:701b:1500:3451:57e0:5a2e:dc45

Innovative Counseling Services, Inc.

CLINICIAN-PATIENT AGREEMENT AND FINANCIAL RESPONSIBILITY