Credit Card Form and No Show/Late Cancel Policy Effective January 1, 2023

It is very important that you keep your scheduled appointment with us, and arrive on time for your in-person or telehealth session. Our counselors have booked schedules and we have a waiting list for patients that want to be seen. As a courtesy, and to help patients remember their scheduled appointments, Counseling Resource Services sends a text message, or email reminders, or confirms by telephone 48 Hours in advance of the appointment time. If your schedule changes and you cannot keep your appointment, please contact us as soon as possible so we may reschedule you, and accommodate those patients who are waiting for an appointment. As a courtesy to our office as well as to those patients who are waiting to schedule, please give us at least 24 hours’ notice. If you do not cancel or reschedule your appointment with at least 24 hours’ notice, we will assess a $50 “no-show/late-cancel” service charge to your account. This charge is not reimbursable by your insurance company. You will be billed directly for it. After three consecutive no-shows to your appointment, our practice may decide to terminate its relationship with you.

I understand the “no-show/late-cancel” policy of Counseling Resource Services, Inc. and agree to provide a credit card number, which may be charged $ 50 for any no-show/late cancel of a scheduled appointment. I understand that I must cancel or reschedule any appointment at least 24 hours in advance in order to avoid a potential no-show charge to the credit card provided.
Copay Information: If you are required to pay a copay by your insurance then we will require a credit card be held on file. You Copay will be charged by the Friday following your appointment.

Credit Card Information for Copays and No Show/Cancellations: