Core4 Therapy Group’s office policies and procedures are outlined below. Please initial beside‬ each blank below to indicate that you have read and agree to our office policies and procedures.‬ A copy will be provided to you upon your request.‬

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• I understand that evaluation reports, therapy plans, and progress notes will be kept confidential unless I sign an Authorization to Release Information form indicating specific information to be shared and with whom to share the information. I have been provided a notice of my privacy rights as required by law and I understand therapist- patient confidentiality.

• I understand that I will be charged in full to cover the cost of replacement of any equipment belonging to Core4 Therapy or any material that is not returned at the discretion of the therapist.

• I understand that scheduled appointment times will be reserved for me and that keeping the appointment is my responsibility.
• I understand that a 24-hour advanced notice is required for canceling or rescheduling an appointment. If I am unable to keep my appointment, I will cancel at least 24 hours in advance.
• I understand that if I do not show or if I do not give 24-hour cancellation notice, I will be charged a $25 fee.
• I understand that if I am late to an appointment, the appointment will still end at the scheduled time, but will be billed in full.
• I understand that if I do not show for two consecutive appointments or three appointments total without contacting Core4 Therapy Group, I will lose my standing appointment time and I will need to call to schedule an appointment each week with times that are available.
• I understand that if I cancel excessively (25% or more of scheduled appointments), I will need to schedule weekly appointments instead of holding a standing appointment.

• I understand that an adult must stay on the premises of Core4 Therapy while the client is participating in therapy sessions.
• I understand that if the client demonstrates aggressive behaviors, the Core4 therapist reserves the right to stop the session.
• I understand that the client and responsible adult will remain in the waiting room until invited to the therapy room by the therapist.
• I understand that the use of appropriate language will be used at Core4 Therapy.
• I understand that I may ask for privacy when discussing my child’s therapy session.

• I hereby authorize the direct payment of my medical benefits to Core4 Therapy Group on my behalf for any services provided to me by the providers.
• I understand that I will be required to provide a copy of my insurance card (front and back) to the office staff at Core4 Therapy before therapy services are provided.

• I understand that I am financially responsible for my health insurance deductible, co- insurance, or non-covered services.
• I understand that my patient portion is due at the time of service.
• I understand that if my child is seen outside the office, I must keep a credit card on file or have an ACH withdrawal in place for my patient portion to be paid at the time of the session.
• I understand that if my insurance plan requires a referral, I must obtain it prior to my first visit,
• I understand that if my health insurance plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided.
• I understand that if I am uninsured or choose to not use my health plan coverage, I agree to pay for the services rendered to me at the time of the service.
• I understand that the full balance is due at the time of receipt.
• I understand that if I do not pay my bill or make arrangements for such payments, I will be responsible for any additional fees or collections costs, including attorney fees, which may accrue in pursuing payment of my balance.
• I understand that if payment is 60 days past due, my child’s therapy will be put on hold.
• I understand that if my balance is $300 or more, my child’s therapy will be put on hold until the balance is paid.
• I understand that returned checks will be charged an additional $25 to the amount due.
• I understand that special financial arrangements must be approved by Core4 partners with a payment plan in writing signed by the Core4 partners and responsible party.
• I understand that payment may be made via cash, check, credit card, and/or health savings accounts, ACH withdrawal, or Venmo.
• I understand that I may securely keep a credit card or ACH withdrawal form on file for payments.

• I understand that I have the option of signing up for the patient portal where I may securely view documents uploaded by Core4 Therapy related to therapy progress or financial information as well as share documents on the patient portal for Core4 Therapy to view securely. To access the patient portal, go to www.core4therapy.com and click on the patient portal tab. Please choose “I am an existing client” followed by the pink bar stating, “never booked online with us before”, then follow the prompts. Enter the guardian’s phone number and email that is on file with Core4 Therapy and then enter the patient’s birthdate.

• By initialing this box you agree to receive conversational TEXT messages from [Core4Therapy Group] at the phone number provided above. You may reply STOP to opt-out at any time. For assistance, reply HELP. Messages and data rates may apply. Message frequency will vary. Learn more on our (Privacy Policy and Terms and Conditions hyperlink)

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• I understand that I may discontinue services at any time and that Core4 Therapy may discontinue services if I fail to adhere to the office policies.
• I understand that Core4 Therapy reserves the right to discontinue services at any time if the safety of a staff member or therapist becomes a concern.

I have read and understand this Statement of Agreement and agree to its terms and conditions.