Intensive Registration Part III

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Name of Participant(required)

Deposits

A non-refundable, non-transferable deposit of $1000 (U.S. Currency) per week and per participant along with a signed Intensive Program Agreement Form is required to activate scheduling of your intensive program.

For intensives scheduled within seven (7) days of the start date, a $2500 (U.S. Currency) non-refundable, non-transferable deposit per participant and a signed Intensive Program Agreement Form is required to activate scheduling of your program.

Visa or Mastercard can be used for non-refundable deposits only

By signing this section, I affirm that I understand and am in agreement with the above policies.

Confirm Full Name of Participant and Signer(required)

 

 

 

Deposit Payment

Are you the cardholder?

16-digit card number. Your information is secure.

3-digit security code

Format as 01/2017

Billing Zip Code(required)
Name of Cardholder(required)

 

I hereby state that I authorize payment of charges to Psychological Counseling Services. This credit card authorization has been signed electronically and my signature may not be identical to my written signature. 

 

 

Payments

(a) Intensive program services are cash programs and pre-payment is required. Payment is due in full  by the due date indicated on your confirmation letter. The intensive coordinator will notify you of your balance due. The cost of your program includes testing fees, supplies and administrative fees.

(b) I understand that the balance of my program is due by wire transfer, cashiers check, or cash, and that the balance is due prior to the beginning of my program.

(c) Unless arranged before the program, I understand that if payment is not received in full by 9:00am on the Friday prior to the program beginning the card I put on file for my deposit will be charged the remaining balance due along with a late payment fee of $250 to $500.

(d) In the event that additional scheduling is done on an immediate and/or urgent basis, I understand that payment in full is required for the immediate and/or urgent additional services.

(e) In the event that I (the client) schedule and pay in full for an intensive, I understand and accept the terms even if I choose not to receive services.

By signing this section, I affirm that I understand and am in agreement with the above policies.

Confirm Full Name of Participant and Signer(required)

 

 

 

Conditions/Definitions

(1) Any outstanding balances on my account(s) must be cleared prior to the beginning of the Intensive Program.

(2) Once you begin the program, there are no refunds. Should you or a therapist request sessions in addition to your schedule, we will do our best to accommodate you. No schedule changes can be made by the client(s) unless initiated by PCS. These schedule changes must be paid for at the time the change is made.

(3) Please note that once confirmation has been sent you are responsible for payment in full by the specified due date. This money will not be refunded to you for any reason within fourteen (14) days of your start date I accept these terms even if I choose not to receive services.

(4) A fourteen (14) day notice is required to reschedule your program and will incur a reschedule fee.  Your program must be rescheduled within six (6) months of the original schedule date.  If not scheduled within this time the program will be considered cancelled and the deposit will be forfeited.

(5) This agreement form with your signature will be supplied to the credit card company for any charges disputed.

By signing this section, I affirm that I understand and am in agreement with the above policies.

Confirm Full Name of Participant and Signer(required)

 

 

 

Intensive Program Insurance Waiver and Agreement

This office does not assume responsibility for billing an insurance carrier for Intensive Program services. Since intensives are cash programs, the patient is responsible for billing their insurance on their own, if they choose to do so. The patient is responsible for collecting any needed receipts. In the event this office inadvertently receives an insurance payment for these services, this office will redirect the payment back to the carrier and instruct them to pay the patient or insured directly.

  • I understand that I am¬†responsible for obtaining any pre-certification for Intensive services without the assistance of Psychological Counseling Services, Ltd, the professional staff members, or administrative staff members.
  • I¬†understand that verification of benefits or pre-certification of services does not guarantee that an insurance carrier will cover this type of outpatient intensive service¬†and that I¬†agree to pay for these services in advance.

By signing this section, I affirm that I understand and am in agreement with the above policies.

Confirm Full Name of Participant and Signer(required)

 

 

 

Information Regarding Participants

Name of Participant(required)

Add Additional Participant?

Please specifiy dates requested:

 

Each participant is required to sign and date this agreement form.

I/We agree to the terms and conditions within this document:

Confirm Full Name of Participant and Signer(required)