MISSED APPOINTMENT/LATE CANCELLATION CHARGES

By signing below, I acknowledge that I am responsible for payment of charges by Calissa Welch, LCSW for missing an appointment without at least 24-hour notice of cancelation. I acknowledge that the amount for which I am responsible in the event of a late-canceled or missed appointment is $50.00. I agree to pay this amount within 30 days of my late-canceled or missed appointment. I understand that my health insurance will not be responsible for payment of any missed appointments. 

*(I understand that emergencies, bad weather, and scheduling conflicts do have the potential to interfere with our scheduled appointments. I try to be flexible with this, allowing for an occasional missed appointment or late cancellation without charge. If sessions are frequently missed or canceled late, I must request the missed appointment/late cancellation fee. I also must request the missed appointment/late cancellation fee if you have missed an appointment during my most-requested appointment times: mornings before 9:00am, afternoons/evenings after 3:00pm, or any weekend appointments. These are times where cancellations have the most impact on my ability to serve other clients, so please be mindful of this when scheduling during these times.) 

Furthermore, due to the importance of consistency in therapy, 3 or more late cancellations and/or no shows could result in the discontinuation of care. 

Client or Parent/Guardian Signature:

______________________________________ Date:__________________

Client or Parent/Guardian Signature:

______________________________________ Date:__________________