12 Jefferson Boulevard Staten Island, New York 10312
718-966-0317 Fax 917-791-8248
CANCELLATION POLICY
PLEASE READ CAREFULLY!!!!!!!
We have an EXTREMELY strict Cancellation and No Show policy!
We require a 12-hour notice to cancel your upcoming appointment (which is lenient).
We assume that ALL circumstances are out of your control, but nonetheless, you must verbally cancel within the 12-hour required notice! Even If such events happen such as: (i.e. sickness, family emergencies, work obligations, school obligations, car break-down, plumbing issues, dog/cat needs the vet, woke up late, bus was late, no transportation, no babysitter, car accident, school paper due, unexpected vacation, conflicting doctor apt, “forgot” about apt, and ANY other given reason.). You are still responsible for the fee. Initials ______
*There is a nominal fee of $35 (instead of our actual session fee of $125) for any Late Cancels or No Shows, which is due at your next appointment. Too many Late Cancels and/or No Shows may result in being taken off the therapist’s schedule.
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*This fee is to offset the cost of your therapist not having enough time to schedule another client in your scheduled slot. We are not a medical office where 4 patients are scheduled in one time slot. Your time slot is specifically yours, so if you Late Cancel or No Show, your therapist is unpaid for your unexpected event. Your insurance company will not pay for cancelled/missed appointments, and are aware itbecomes the client’s responsibility.
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* Your appointment is YOUR responsibility only and the expectation is that you show up and or cancel within the 12-hour period of your appointment. We may call to confirm your appointment the night before, AS A COURTESY only! If for some reason you do not receive a call confirming, the appointment YOU made, your appointment still exists. Your appointment is your appointment that you scheduled!
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*To ensure ongoing communication with our clients, we have an electronic messaging port with time/date stamped, that allows clients to call and leave a message when the practice is closed, including weekends. The phone system keeps tracks of all incoming phone numbers.
*The best source of communication is email, which is also time-stamped for your records. You may contact us with any cancellations or scheduling issues, as it is checked frequently, even when the practice is closed. You may email us at:
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Just to reiterate our stance, you are hereby signing and agreeing with our above-stated Cancellation/No Show Policy. So if the unfortunate time comes that you are unable to cancel your appointment within the 12-hour period, please be courteous to our staff, as they are not the policy implementer’s. Any issues or concerns with our cancellation policy, the Director, Elissa Donner-Guzman LCSW-R CASAC will gladly discuss with you.
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X______X______Today’s Date
(Client Signature or Legal Guardian)