OUTPATIENT SERVICES FEE AGREEMENTOutpatient Services Fee Agreement • March 20th, 2017
I, have chosen to participate in outpatient counseling either voluntarily or in order to comply with mandates. I agree to attend all scheduled sessions and pay all fees at the time of service. I understand that if I have cancelled or missed more than one appointment without sufficient notification, I will be removed from the schedule and a $35 cancellation fee will need to be paid first before making my next appointment. I also understand that any outstanding Fees for treatment programs (to be in compliance with DUII mandate) MUST BE PAID IN FULL before Kolpia Counseling Services will issue a Completion Certificate.
