Authorization

(This authorization is required for all clients prior to scheduling a session - excluding clients on Medicaid)

By filling out the form below, I authorize Tranquil Journey Therapy, PLLC to charge the payment method I have provided for amounts that become due under the Practice's financial policies, including:

• Therapy session fees

• Initial consultations (when applicable)

• Insurance copayments

• Coinsurance

• Deductible amounts

• Self-pay balances

• Outstanding balances after insurance processes claims

• Late cancellation or no-show fees, when permitted by law and consistent with Practice policy

• Other fees that I have previously agreed to in writing

I understand that insurance benefits are not guaranteed and that I remain financially responsible for charges not paid by my insurance carrier.