Credit Card Authorization

∗ I understand that all fees are directly my responsibility to pay at the time of service.

∗ I understand that 24-hour notice is required for cancellations or I will be charged $125.00 for the missed session.

∗ Excessive cancellations or changing appointment times are disruptive to the therapeutic process as well as the therapist’s schedule.

∗ I may be charged for any extra services requested. I understand that those charges will be discussed prior to services rendered.

∗ Services will not be rendered until fees have been paid.

∗ Insurance companies will be billed and paid directly to Evolving Reflections. I understand that I will be responsible for all outstanding monies not covered by the insurance company. For “Out of Network” insurance companies, paperwork can be provided (upon request) for you to submit a claim.

∗ Checks are accepted however, there will be a $50.00 charge for any returned check.

∗ If your account goes into Collections, there will be a 40% fee added to your balance.

I agree to take financial responsibility for my session(s). I will pay for services at the time they are rendered or in advance.

I authorize use of my credit/debit card by Evolving Reflections for payment, outstanding monies owed, as well as, missed appointments: