Third Party Financial Responsibility Agreement

Financial Policies 

The following is a Financial Responsibility Agreement for those individual’s or agencies who have elected to sponsor a client’s counseling expenses with MCO.  It is important to understand the financial responsibilities and policies set forth by MCO.

  • I agree to be responsible for the charges the scholarshipped client incurs as a result of counseling and/or assessment.
  • I understand that charges are based on the amount of professional time used/reserved for the scholarshipped client by their request regardless of whether they appear for their session or not.
  • I understand that all payments are due at the time services are rendered.
  • I understand MyCounselor does not accept cash and all checks are processed electronically via check draft.
  • I understand 24 hours before the appointment is the LATEST the scholarshipped client can cancel. Please let us know as soon as possible if unable to use the time reserved. Late cancellations result in people who need help being delayed in getting help unnecessarily.  Frequent late (day before) cancellations will result in a 7 day cancellation / reschedule notice requirement. 
  • I understand that only the scholarshipped client is able to request an appointment or cancel a scheduled appointment.
  • I understand if I reserve 4 hours or more of professional time in a week this is considered "intensive" and is subject to a 7 day cancellation / reschedule notice requirement.

Fees

  • I understand the payment method I provide MyCounselor.Online will be charged my membership fee every 4 weeks starting the day the scholarshipped person begins membership.
  • Membership includes 2 45-minute units of counseling every 4-week billing cycle.
  • If the the scholarshipped person schedules more than 2 units in a 4-week billing cycle, I will be charged an additional session fee for each unit I schedule the day of the session.
  • In addition to monthly membership fees there will be a one-time Assessment & Matching fee of $35 when the scholarshipped person begins membership.
  • Unused sessions units roll over month to month.

 

Membership Fees

  • Assessment & Matching Fee = $45
  • Advanced Practice = $450 every 4 weeks
  • Certified = $310 every 4 weeks
  • Resident = $252 every 4 weeks

 

Additional Session Fees (Member Rate)

  • Advanced Practice = $225 per additional session unit
  • Certified = $155 per additional session unit
  • Resident = $126 per additional session unit

 

Non-Member Fee Rates

  • Assessment & Matching Fee = $55
  • Advanced Practice = $280 per session unit
  • Certified = $195 per session unit
  • Resident = $165 per session unit

Automatic Credit Card Billing Authorization

 

Credit or Debit Card Authorization

I hereby authorize Paraclete Ministry Group LLC, dba MyCounselor, to automatically bill the card I have provided to MyCounselor. I guarantee and warrant that I am the legal cardholder for this credit card and that I am legally authorized to enter into this agreement.  

 

eCheck Authorization

I authorize Paraclete Ministry Group LLC, dba MyCounselor, to automatically initiate either an electronic debit or to create and process a demand draft against my bank account using the routing and account number I have provided. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law.  

 

Appointment Cancellation / Reschedule Policy 

I understand that if I fail to give notice of cancellation or rescheduling requests by using the scheduling software link, calling 855-755-3797, or emailing receptionist@mycounselor.online at least 24 hours before my scheduled appointment I am responsible for the full fee of my session and my account or credit or debit card or checking account will be charged for the time I have requested to be reserved for me. I understand that I may not schedule, reschedule, or cancel appointments for other adults.  

 

Membership Cancellation & Refund Policy

Memberships may be canceled at any time. Accumulated session credits on your account are non-refundable and will expire 12 months from the time of your cancellation. The scholarshipped person may continue to use accumulated session credits after membership cancellation and prior to their expiration.

 

Individuals Being Scholarshipped

Please give the name or names of the individuals being scholarshipped in the field(s) below.

 

Consent and Agreement to Terms of Service

When you have read this document please electronically sign it below.  Your signature indicates you have read and understood the conditions as read and agree to receive services under these conditions.

Leave this empty:

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Signature Certificate
Document name: 3rd PARTY FINANCIAL RESPONSIBILITY AGREEMENT
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