PLEASE READ THE FOLLOWING AGREEMENT CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE BRING THEM UP PRIOR TO YOUR FIRST SESSION BY PHONE OR EMAIL. YOU ARE REQUIRED TO SIGN AND SUBMIT THIS FORM PRIOR TO BECOMING A PATIENT AT FEELING GOOD THERAPY AND TRAINING CENTER. BY SIGNING THIS FORM, YOU ARE AGREEING TO THE TERMS OF FINANCIAL RESPONSIBILITY ASKED OF YOU IN ORDER TO BECOME A PATIENT OF FEELING GOOD THERAPY AND TRAINING CENTER.
Services at Feeling Good Therapy and Trainig Center (FGTTC) include but are not limited to psychotherapy, psychological testing, and evaluations, consultation with others about your care, reading supporting documents about your care and preparing documents for your care.
No services will be done without your prior agreement.
Our clinicians are considered out of network providers with all commercial insurance companies. This means you are responsible for making payments for the services you receive either prior to, or at the time of service, directly to your treating clinician.
If you are interested in submitting claims to your insurance carrier you are welcome to ask your clinician for a superbill, which will be provided to you at no additional charge.
FGTTC is not responsible for the transactions between you and your insurance carrier, nor does it guarantee payments from your insurance carrier.
All appointment cancellations or changes must be made within 48 hours (2 work days) prior to the appointed time. All late cancellations and appointment no-shows will be charged at the full rate. All cancellation notices must be made either by a phone call to the office (510-400-6160) or by email to email@example.com
Should you choose to discontinue services before reaching your therapy goals, you are responsible for clearing payments for all the services you have received up to that point, there are no refunds for services rendered. You are not responsible for paying for any future appointments, should you cancel them within 48 hours (2 work days) prior to the appointed time.
In order to become a patient at FGTTC, you are required to provide a valid credit card on file. Your credit card on file will be charged for late cancellations or no-shows, as well as incidental charges that have not been cleared prior to or at the time of service. We keep your financial information confidential and use HIPPA regulations in the safe keep of your information. Please be prepared to provide a valid credit card to your clinician on the day of your first appointment.
Most therapy sessions are at the standard length of 50 minutes. However, frequently it becomes clinically beneficial to sign up for a double session, which lasts 100 minutes (1 hour and 40 minutes). All double sessions will be offered with your prior agreement. The fee for double sessions is charged at the same hourly rate times the number of sessions.
Your signature below means you have carefully read, understood and agree with the statements above.