This form confirms your agreement to receive therapy services from Inner Peace & Enlightenment Therapy as a self-pay client,
meaning you are responsible for payment of all services rendered and are choosing not to use insurance for reimbursement.

1. Acknowledgment of Financial Responsibility

I understand and agree that:

• I am responsible for payment in full for each therapy session at the rates outlined below:
  • 53-minute session: $155
• Additional services (e.g., letters, phone calls over 15 minutes, legal consultations) are billed separately
• Payment is due at the time of the session unless prior arrangements have been made

2. Credit/Debit Card Authorization

I authorize Inner Peace & Enlightenment Therapy to charge my credit/debit card on file for session fees and any applicable additional fees.

Failure of a card to process may result in termination of services until payment is made.

3. Cancellation & No-Show Policy

I agree to provide at least 24 hours' notice for cancellations or rescheduling.

If I cancel or fail to attend a session with less than 24 hours' notice, I will be charged the full session fee.

This policy ensures that my scheduled time is reserved exclusively for me.

4. Insurance Waiver

By electing self-pay, I waive any insurance billing by Inner Peace & Enlightenment Therapy for services rendered.

I understand that if I later decide to submit claims to my insurance, it is my responsibility to do so. The practice is not responsible for insurance reimbursement or denials related to these services.

5. Agreement to Terms

I have read, understood, and agree to the terms above. I acknowledge that this agreement is part of my informed consent and does not alter my clinician's scope of services or therapeutic relationship.