Susan Davis, MA LMHC

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Name:___________________________________________________Todays Date:_______________________



Cancellation and Missed Appointment Policy

Scheduled appointment times are reserved especially for you. If an appointment is missed or canceled with less than 48 hours notice, you may be billed according to the scheduled fee and instructions of your benefit plan. Insurance cannot be billed for fees associated with missed or canceled appointments, therefore you may be responsible for the entire fee if appointments are canceled without appropriate notice or consultation. Rescheduling for the same week may be a possible alternative to being charged, as well as a phone session. Therapy is a commitment on the part of the client as well as reserved time scheduled by the practitioner.

Initial here:_______________________


Credit Card information:

Number ____________________________________________________________________________

Expiration date ___________________________

Zip code to where the bill is mailed _____________________________________

Please note: credit card will not be billed without consultation regarding the missed appointment.