Billing Disclosure

By signing this document, you are consenting to services with Nine Lives Counseling Service, as well as indicating you understand the billing policies of the agency.

Professional Disclosure Statement – Billing Policies

Understand that at this time, counseling services through Nine Lives Counseling Service may not qualify for reimbursement through health insurance. By entering into a professional counseling relationship with Nine Lives Counseling Service and Aiden Rohwer-Nutter, I understand that I am agreeing to the following terms and conditions regarding payment for services. Cost of Services The cost of sessions will be listed clearly on the company website and discussed with me during the first intake session. Any changes to the cost of services will be discussed with me four (4) weeks prior to the implemented change, and I have the right to terminate services at any time. I understand that I am responsible for the cost of services, and will be billed directly for services. The parent or legal guardian of a minor client (under 18 years of age) is responsible for payment on the minor’s account. This form must be signed by the parent or legal guardian. Billing and Payment Clients will receive a bill monthly via the email provided on their intake paperwork. Payment for the invoice is expected within 30 days of receipt. Payment can be made through the company’s website using a credit card, Apple Pay, or iDeal account. Checks and/or cash are not accepted at this time. If the client is unable to pay, they may inquire about a payment plan and/or a sliding scale for services. Payment plans and sliding scale costs are at the discretion of Nine Lives Counseling Services. Termination of Services due to Nonpayment If a client fails to pay their outstanding invoice within 30 days of it being emailed to them, a warning email will be sent and the client will have an additional 7 days to pay their outstanding invoice. Failure to pay after the 7 day grace period will result in immediate termination of services. Outstanding bills may be sent to a collection agency if the client fails to pay their invoice at this time. I understand and consent to entering a counseling relationship with Nine Lives Counseling Service and Aiden Rohwer-Nutter.
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