If you have any concerns or questions, please be sure to discuss this form with your therapist. In signing this consent, I understand and agree to the following regarding billing and payment for charges related to my treatment and therapy at Dunham Counseling Center, Ltd.

• There is a 24 hour cancellation policy. When I schedule an appointment, the therapist reserves an hour of time and if I cannot attend a session, I must provide 24 hours notice or my therapist will charge me for the session. (Amounts charged for missed sessions vary from therapist to therapist, please discuss this fee with your therapist.)
• Payment of services (co-pays and deductibles) is expected at the time of service unless separate arrangements are made with my therapist.
• If health insurance is used for my sessions, Dunham Counseling Center, Ltd. will seek reimbursement from the health insurance company. ANY unpaid amounts, co-payments and deductibles are MY responsibility to pay.
• If Dunham Counseling Center, Ltd. is unable to charge unpaid balances to my credit card and the account remains unpaid over 90 days then it may be turned over to collections.
• Dunham Counseling Center, Ltd. requires that clients provide a credit card number to keep on file for delinquent accounts over 60 days.
• I authorize recurring charges for fees, co-pays and deductibles to be charged to my credit card monthly.
• I understand and consent to the above payment terms for my treatment at Dunham Counseling Center, Ltd. and I authorize Dunham Counseling Center, Ltd. to keep my credit card number on file and authorize charges to my credit card for my unpaid balances for counseling I received which are over 60 days past due.

Your therapist has a late cancellation policy of 24 hours notice. If you do not show or cancel within 24 hours you will be charged. Cancellation fees vary by therapist. Please discuss the cancellation fee amount with your therapist.