Member Financial Policy

All members will pay the initial evaluation fee of $_______. A $3.00 convenience fee will be charged for using a debit or credit card. The month following the member’s initial appointment, the member’s checking and/or savings account will be drafted $_______ on the 1st or 15th of every month until membership is canceled or terminated. The draft may occur the last business day prior to the selected date, if the selected date is on a weekend and/or holiday. Members may cancel their membership at any time with a 60-day written notice. If your draft is declined for any reason, you will have 15 days to resolve the debt of $______ plus a $50.00 fee. If you fail to do so, your membership will be terminated. By signing below, you acknowledge and understand the member financial policy.
 
 
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Printed legal name of individual receiving treatment
 
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Printed legal name of parent/legal guardian responsible for payment
 
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Signature of individual or parent/legal guardian                    Date
 
 
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