Cancellation Policy

Please complete the following form prior to your first appointment with us. If you have any questions, please call us at 859.554.0740.

  • Patient Information

  • No Show, Late Cancellation and Time Policy

    1. I understand that I will be charged a LATE CANCELLATION fee that is equal to the cost of a regular session if I fail to give at least 24 hour notice prior to cancelling my appointment.

    2. I understand that I will be charged a NO-SHOW fee that is equal to the cost of a regular session if I fail to show for my appointment. If there is an emergency, notify our office within 48 hours of the missed appointment.

    3. I understand that if I choose to bill my insurance company for services received, I must verify benefits with my carrier prior to service as I am liable for any charges not covered due to lack of coverage or denial made by the carrier. If my therapist is considered out of network with my insurance provider or plan, I may use my FSA or HSA to cover services or Willow Creek Counseling Center, LLC may provide a CMS-1500 out of network form that I may submit to my insurance company. In the event that I have a late cancellation or no-show for my scheduled appointment, my insurance will not be billed and the fee for the missed appointment will be my full, out of pocket responsibility.

    4. I understand that the therapy session will last 50 minutes. I understand that if I am late to the appointment, the session will still end at the regular scheduled time. If my session goes over the scheduled 50 minutes, my session fee will be pro-rated for the additional time spent in session. I understand that it is not always possible for my therapist to stop our session and notify me of the time. I understand it is my responsibility to stop the session if I am unable to pay for an additional session fee if the session is going over the allotted 50 minutes.

  • Signature Agreement

    By signing this, I am agreeing to the above stated terms and stipulations regarding the services I receive from this therapist.
  • Patient or Guardian Signature (if minor)