The Center for LifeSkills and Stefanie J. Peck, M.A. CCC-SLP require payment at time of service for office visits. Payments must be made by cash, check or credit.
-I understand that I am ultimately responsible for paying my entire bill should any third party payor deny payment for any reason.
-I understand that payment is required at the time of service, by cash, check or credit, unless alternate arrangements are made. In some instances, an invoice will be sent. Invoices are due within 30 days of being sent.
-I understand that there will be a $25 charge for balance that are 30+ days past due (due date determined by date of session or date of sent invoice, whichever is applicable).
-I understand my insurance benefits, including deductible, co-pay, co-insurance and session limits. I agree to keep track of the number of sessions attended and understand that I am responsible for paying for any sessions that my insurance does not cover.
-All health information is kept safe, as required by law. I acknowledge that I have read The Center for LifeSkills/Stefanie Peck Notice of Privacy Practices sheet
Please notify your therapist of any vacations/scheduled medical appointments/school functions, etc., so that make-up sessions may be scheduled. We appreciate advance notice of these cancellations, as we can use those time slots for other make-up sessions or meetings.
-I understand that my child must be present at 75% of his/her regularly scheduled sessions, in any rolling 3-month period. If the attendance percentage drops below 75%, the regularly scheduled time slot may be forfeited.
-I understand that there will be a $45 charge if a session is missed without notification. I must notify my therapist about a cancellation at least 8 hours in advance of the scheduled appointment to avoid the $45 charge. I understand that this fee cannot be paid for by a third-party payor and will be my responsibility.
Consent to Treat
I have read the above policies and agree to the terms. I consent to treatment for my child(ren), fill up form at the bottom by Brenda Richards, Stefanie Peck, or other therapists/student clinicians working in this office.
I give permission for the therapist to accompany my child into the bathroom, if necessary.
I give permission for my child to participate in photos and videos for media purposes for The Center for LifeSkills/Stefanie Peck. My child’s first name, photo and/or videos may be used and seen in printed marketing materials, website content, and/or our Facebook business page. Media will not be shared with any third parties. This release will remain active until I or my child's guardian notifies The Center for LifeSkills/Stefanie Peck.
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