Common use of Client Consent Clause in Contracts

Client Consent. My signature below indicates that I reviewed this document, agree to the policies, and authorize the services. I accept financial responsibility for payment of services received, and for payment of late cancellation fees. If I use insurance to pay all or a portion of the charges, I hereby authorize the release of information necessary to process insurance claims filed on my behalf. I acknowledge that I am financial and legally responsible for the full payment of charges for services received in the event my health insurance policy does not cover my claim. I am 18 years of age or older or I have legal custody of this minor child(▇▇▇). Client Signature: Date: Custodial Parent or Guardian Signature: Date: Therapist Signature: Date: ▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ • ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ Care and Counseling offers the option to receive an appointment reminder the day prior to your scheduled appointment by email (up to 2 email addresses) and/or by phone (only 1 phone number permitted). If you choose the reminder by phone, you have the option of a text message or a computer-generated voice message. PHONE REMINDER (only one type of phone reminder can be provided): Text Message: I authorize Care and Counseling to send text message appointment reminders to me on my provided cell phone number. Text message charges from my cell phone provider may apply. Cell phone number to send text messages to: ( ) - Automated Voice Messages: I authorize Care and Counseling to send computer generated voice phone message appointment reminders to me on my provided phone number.