Financial Policy and Consent to Treatment

Current Date*

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Your Name*

First Last

Your Phone Number*

Your Email Address*

Name of Client*

First Last

Name of Client 2 (if applicable)

First Last

Consent*

My fee per session is $100. Payment is due at the time of session by cash, personal check, or Venmo. Fees for missed appointments (virtual or in-person) are the responsibility of the client. Further services may be postponed until previous balances have been paid. The client is responsible for the cancellation of appointments 24 hours in advance by calling 614-436-6080 ext. 2. Cancellations made by other methods may not be retrieved prior to the time of the session and may be considered missed appointments.

During the Covid-19 pandemic, sessions are conducted by phone or video. Confidentiality is maintained.

Notices of Policies and Practices to Protect Your Privacy are available for you to read on this website.

Agreement to abide by Financial Policy and Consent to Treatment.
I have read and understood this financial policy, have had my relevant questions answered, and agree to counsel services to be provided by Robert Forte LPCC, Ltd. I accept, understand, and will abide by this agreement, and I consent to treatment by Robert Forte, LPCC, Ltd.

I agree to this Financial Policy and Consent to Treatment