Form – Electronic Payment and Communications Disclosure
Electronic Payment and Communications Disclosure
If you wish, you may pay fees electronically – through funds transfer or using a payment card using any of the following services:
- Therapy Notes
Please Be Aware of the Following:
We have a responsibility to protect your confidentiality, and thus we wish to make sure that your use of the above payment services is done as securely and privately as possible. However, after using any of the above services to pay your fees that service may send you receipts for payment by email or text message. These receipts will include our business name, and could indicate that you have paid for a therapy session. It is possible the receipt may be sent automatically, without first asking if you wish to receive it.
We are unable to control this in some cases, and we may not be able to control the choice of the email address or phone number to which your receipt is sent.
Before using one of the above services to pay for your session(s), please consider:
The email addresses or phone numbers you may have used to receive these electronic receipts previously (since they may be automatically sent there when you make a payment for our services).
Whether any of those addresses or phone numbers are provided by your employer or school (If so, the employer or school will most likely have the right to view the receipts that are sent to you).
Whether other parties may have access to these addresses or phone numbers, and whether you would not wish those parties to see these receipts or reveal them to others. (In other words, you should consider any possible risk to your privacy or any possible danger to you or someone else that might result from someone knowing you had sought counseling).
Holds on Electronic and Flex Account Payments
Please be aware that even if your payment goes through and is authorized at the time that we run your card, there is a possibility that your payment could later be frozen or denied. In the event of this happening, you are responsible for ensuring that full payment is made by other means. This may occur if your bank investigates your account activity or If you are using a Health Savings Account (HSA) or Flexible Spending Account (FSA) payment card, I have read and understand this statement and agree to its terms.