I agree to be responsible for the following charges, and I am
aware that no progress or completion, paperwork will
be released to me or to any third party until I have paid my balance in full.
I understand that if I miss a session, I must call before the session and get approval in order
to be excused. I understand
that I will be charged $10.00 per each unexcused absence. Fees must be paid at or before the
time of service. Services will
not be rendered without payment. (You will not be allowed to attend group/individual sessions if
you do not have
payment). Unless you have made other payment arrangements. You will guarantee that payment will
be made in
compliance with those arrangements. Failure to do so, it will void original arrangement, then
fees must be rendered for
services. Please be advised that any outstanding unpaid balances over 30 days will be reported
to an outside collection
agency.
I understand that if the courts/probation are paying for my classes, I am still responsible to
pay for any random testing or
unexcused absences I acquire throughout the treatment process.
Adult/Youth Services, LLC., I understand that my signature does not bind me to treatment, but it
does make me
responsible for charges incurred prior to my termination.