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.

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 [on this website/material]. Please use judgment and conduct due diligence before taking any action or implementing any plan or practice suggested or recommended [on this website/material].

Also, please note that I don’t make any guarantees about the results of the information applied [on this website/material]. I share educational and informational resources that are intended to help you succeed in [coaching area]. 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: January 7, 2022


Signature Certificate
Document name: Clinician-Patient Agreement and Financial Responsibility
lock iconUnique Document ID: af3030acfa3dfe393d0b80d611630dc10230a79e
Timestamp Audit
October 31, 2021 5:51 pm EDTClinician-Patient Agreement and Financial Responsibility Uploaded by Jean Pollack - [email protected] IP 71.173.146.2