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CANCELLATION POLICY FORM
Speech Journey Therapy Guidelines
Sessions
• Sessions are usually one hour in length, which includes any time necessary for parent consultation, scheduling and billing issues.
Commitment/Scheduling
• Your treatment and care are of the utmost importance to me and I value nurturing a mutually respectful relationship with you and your family. A strong commitment to the process is essential for steady progress.
• Once a session is scheduled,
24-hour notice is required for any cancellation or postponements.
Clients will be charged in full for any session cancelled less than 24-hours in advance.
I will do my best to accommodate a makeup session. However, if we cannot find a mutually desirable time to reconvene within a one-week period, it will be considered a cancellation and the full session fee will be charged.
• Occasionally, I may ask if you can move a session time. Please know if I am doing so, it is probably because I am trying to accommodate another client and that
your scheduled session
comes first.
Billing
• Payments may be made via cash or check (made out to “Speech Journey”). There will be a $35 fee charged for any returned checks.
• Insurance reimbursement may be possible. You will be provided with receipts of payment to submit to your insurance company. It is your responsibility to inquire about your plan’s benefits. I will provide whatever assistance I can in helping you receive the benefits to which you are entitled, however, you (not your insurance company) are responsible for full payment of my fees.
Your signature below indicates that you have read this agreement and agree to its terms.
Client Name
*
Client Email Address
*
Signature of Client or Parent/Guardian
*
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