In consideration of the mutual promises herein contained, the parties agreed as follows:
1. The client herein retains and employs the Counselor to conduct assessments and/or mental health counseling services. In consideration of the services rendered, client hereby agrees to pay Counselor $115.00 (one-hundred and fifteen dollars) at the time of the 45-50 minute session and any regular fee increase as may occur unless otherwise stated. If I am a covered provider on your insurance and you have met your deductible, you will only pay your copay at the time of service. Clients paying by check will need to furnish their Driver’s License Number. Client agrees to a $25.00 penalty for any bounced checks and further agrees to by cash or money order thereafter for counseling services as checks will no longer be accepted.
2. Payment of services is required regardless of any problems or delays the client may have with his/her insurance company.
3. 24-HOUR NOTICE CANCELLATION POLICY: CLIENT WILL BE CHARGED $50.00 FOR ANY COUNSELING SESSION WHICH THE CLIENT DOES NOT CANCEL 24 HOURS IN ADVANCE. PLEASE RESPECT THIS POLICY.
4. ALL PAST DUE ACCOUNTS WILL BE TURNED OVER TO A COLLECTION AGENCY.
5. Client, including all persons now or hereafter becoming obligated or liable for payment hereto, agrees to pay all costs of collection, including reasonable attorney’s fees and court costs. Such attorney’s fees and costs shall include but not be limited to, fees and costs incurred in all matters of collection and enforcement, construction, interpretation before, during and after the suit, trial proceedings and appeals.
6. This agreement supersedes any and all other agreements, either oral or in writing between the parties hereto with respect to the subject matter hereof, and no other agreement, statement, or promise relating to the subject matters of this agreement which is not contained herein shall be valid or binging unless signed in writing by both parties.
7. The validity of the agreement and of any of its terms of provisions as well as the rights and duties of the parties hereunder, shall be governed by the laws of the County of Pinellas, State of Florida.
Licensed Mental Health Counselor MH2820
Certified Practitioner of Psychodrama
& Group Psychotherapy
National Certified Counselor
2555 Enterprise Rd. Suite #2
Clearwater, FL 33763