Clinician-Patient Agreement and Financial Responsibility


Innovative Counseling Services, Inc.

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.

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.

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.

 

Leave this empty:

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Signed by Jean Pollack
Signed On: November 7, 2021


Signature Certificate
Document name: Clinician-Patient Agreement and Financial Responsibility
lock iconUnique Document ID: 405faf33fdd0b9dd2b55cd04e27943d4bb5b75b8
Timestamp Audit
October 31, 2021 5:51 pm ESTClinician-Patient Agreement and Financial Responsibility Uploaded by Jean Pollack - [email protected] IP 71.173.146.2