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Appointment and Fee Agreement

Please provide your information below and answer all questions.

Click 'submit' when finished.

Billing Agreement
I understand that I am financially responsible for appointments not canceled at least 24 hours in advance of my scheduled appointment.
I understand that keeping my appointment is my responsibility and barring any unforseen emergencies, communicating a cancellation is my responsibility.
I understand that it is my responsibility to inform my therapist of any changes in my circumstances that may affect my fee or ability to pay at my next scheduled appointment.

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© 2023 by Lesa J. Fischer, LCSW. 

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