Payee responsibility for no show/late cancellation policy. We work closely with your insurance company to ensure payment for our services. In the event your insurance company rejects the claims (deductible, ineligibility, etc.) you are responsible for the payment for services rendered. Please be advised that you must provide 24-hour notice for cancellation.

Failure to do so may result in your being charged for the missed appointment

I hereby give permission to furnish information, including a psychiatric diagnosis to my insurance company. In consideration of services rendered, or to be rendered, I hereby assign and transfer to: any benefits.