PAYMENT/CANCELLATION/CONTACT POLICY
PAYMENT POLICY
The patient is responsible for payment in full at the time services are rendered. Phone and Skype sessions can be paid trough PayPal when you schedule your appointment on line. Office sessions can be paid through PayPal, check, or cash. No credit cards.
This office does not accept insurance. If you would like, Dr. Demner will provide you with a monthly statement you can submit to your insurance company for direct reimbursement. Check with your individual carrier to find out details.
CANCELLATION POLICY
Twenty-four (24) hour notice of cancellation is required for all appointments. Failure to keep a scheduled appointment or failure to cancel an appointment more than 24 in advance will result in a charge of $100.00 which will be billed directly to patient.
CONTACT INFORMATION
If we need to contact you in a confidential manner, please fill out the information below that is applicable.
Patient’s Name: _______________________________________________________________________
Home Phone: _________________ Cell Phone: _________________ Text: ________________
Email: ___________________________________ Skype name: ______________________________
If you have any questions, please ask before signing this form. Your signature indicates that you have read the Payment/Cancellation/Contact Policy and agree to enter the psychological evaluation and/or therapy under these conditions. It also indicates that have granted us permission to contact you and leave you a message at the places listed above. If patient is a minor, parent or guardian must sign on behalf of the patient.
Print Name: ___________________________________________________
Signature: _____________________________________________________ Date: _________________
PAYMENT POLICY
The patient is responsible for payment in full at the time services are rendered. Phone and Skype sessions can be paid trough PayPal when you schedule your appointment on line. Office sessions can be paid through PayPal, check, or cash. No credit cards.
This office does not accept insurance. If you would like, Dr. Demner will provide you with a monthly statement you can submit to your insurance company for direct reimbursement. Check with your individual carrier to find out details.
CANCELLATION POLICY
Twenty-four (24) hour notice of cancellation is required for all appointments. Failure to keep a scheduled appointment or failure to cancel an appointment more than 24 in advance will result in a charge of $100.00 which will be billed directly to patient.
CONTACT INFORMATION
If we need to contact you in a confidential manner, please fill out the information below that is applicable.
Patient’s Name: _______________________________________________________________________
Home Phone: _________________ Cell Phone: _________________ Text: ________________
Email: ___________________________________ Skype name: ______________________________
If you have any questions, please ask before signing this form. Your signature indicates that you have read the Payment/Cancellation/Contact Policy and agree to enter the psychological evaluation and/or therapy under these conditions. It also indicates that have granted us permission to contact you and leave you a message at the places listed above. If patient is a minor, parent or guardian must sign on behalf of the patient.
Print Name: ___________________________________________________
Signature: _____________________________________________________ Date: _________________