Helping Hand Counseling Center
3 - AGREEMENT TO PAY
*PLEASE READ, FILL IN SIGNATURE AND DATE AT THE BOTTOM OF THIS FORM
THEN CLICK "SEND" *
I, the undersigned, request that the counselor at Helping Hand Counseling Center
provide professional services to me, the client, and I agree to pay this therapist for services.
If the patient is a minor, and I am paying the session fee, I understand that while I have a right to general information on issues and progress, some information shared in this professional relationship will be held in confidence by the therapist and the minor child. If, at any time, I am dissatisfied with this therapy I will fully discuss my views, reasons and plans with the therapist (and if the client is a minor, with the client named) prior to terminating therapy.
I agree that this financial relationship will continue in effect with the above named professional as long as this therapist provides services or until I inform him or her, by telephone or by certified mail, that I wish to end it. I agree to pay for services rendered to me up until the time I terminate the counseling relationship.
If I do not pay for my phone sessions prior to the date of the session, then services may be terminated. I understand that I am responsible for services provided by this therapist to me.
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Looking forward to working with you! Thank you!
