I understand that I am responsible for my fee payment at the beginning of each appointment. I agree to be responsible for the full payment of fees for services rendered regardless of whether insurance reimbursement will be sought. ____________________________ will honor contractual agreements made with those managed health care companies which stipulate specific reimbursement restrictions.

I hereby consent to treatment by specified provider.  Although the chances for obtaining my goals for therapy will best be met by adhering to therapeutic suggestions, I understand that I have a right to discontinue or refuse treatment at any time.  I understand that I am responsible, however, for any balance due prior to a decision to stop.

I hereby authorize the release of necessary medical information for insurance reimbursement purposes.

I will pay Fees for services to the provider of services.