By checking this box, I hereby agree to all its terms and conditions, and consent to participate in therapy and consultation, as well as agreeing to complete brief evaluations to measure and improve quality of care

*

I grant authorization to YVA to release Private Health Information (PHI) to my third-party payer and any prior authorization that is necessary for billing or to process any claims for services provided by YVA  *

I authorize YVA to bill my insurance payer(s) for charges incurred from services rendered by YVA providers.  I authorize my insurance company or third-party payer to send payments directly to YVA for all services provided.  I understand that I am ultimately responsible for my bill.   *

I accept full responsibility for notifying YVA of any changes in my insurance or third-party coverage while receiving care., failure to do so will result in my being responsible for any unpaid claims.  *

I agree to pay my co-payment, deductible, and/or co-insurance and any outstanding balances owed to YVA.   I will be charged a $50 fee and agree to any terms set by my provider or organization, for any sessions I fail to attend or miss without a 24-hour's notice before the schedule appointment.  *

I agree to receive text messages, phone calls, and/or emails based on appointment reminders.   *

I understand that this is a training facility of master’s level practicum students and recently graduated practitioners without full licensure and agree to be treated by them under the supervision of a licensed clinician. *

Your signature below indicates that you have read the treatment consent form which contains information on clinical services, sessions, professional fees, cancellation and no-show policies, billing and payments, insurance reimbursement, contacting us, professional records, confidentiality, and practice status. By signing the form, you agree to abide by its terms during our professional relationship.   *

I declare that the info I’ve provided is accurate and complete.*