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CRT COUNSELING

CANCELLATION POLICY

When you set an appointment with a therapist, that time is reserved just for you. If you are unable to attend your appointment, CRT requires clients to provide 24-hour notice. The notice offers the therapist time to give the appointment to another client.

The cost for a missed appointment is $50.00. Insurance cannot be billed for missed appointments and you are fully responsible for this charge.

I understand the cancellation policy and agree to give 24-hour notice for any cancellations. I further give CRT Counseling authorization to bill my credit card $50.00 for any appointments that I miss, or that I fail to cancel according to CRT policy.

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Name

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Signature

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Date

Credit Card (Circle One)

VISA MASTERCARD AMEX DISCOVER

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Card Number

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Expiration date

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Zip Code