3rd Party Financial Responsibility Agreement


3rd 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 if I am approved for a weekly payment arrangement I will be invoiced for the full amount of my session and payments will be drawn until my balance is satisfied.
  • I understand MyCounselor does not accept cash and all checks are processed electronically via check draft.
  • I understand 5 pm the business day 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 that all scheduling, rescheduling, or cancellation request must be made by telephone (not email, messaging, text or any other method). 
  • 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

Tier 5 - $175| Tier 4 - $145 | Tier 3- $115 | Tier 2 - $95 | Tier 1 - $45

In addition to the standard session fee, all 1st session appointments will be charged a one-time $30 assessment and setup fee as a non-refundable deposit on the first appointment.

Credit or Debit Card AuthorizationI hereby authorize Paraclete Ministry Group LLC, dba MyCounselor, to charge the credit card 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 AuthorizationI authorize Paraclete Ministry Group LLC, dba MyCounselor, to initiate either an electronic debit or to create and process a demand draft against my bank account. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law.

*If you elect to utilize eCheck MCO will require a voided personal check to facilitate this payment method. 

Cancellation / Reschedule / Refund Policy: I understand that if the scholarshipped client fails to give notice by phone of cancellation or request for rescheduling by 5 pm CT the business day before the scheduled appointment I am responsible for the full fee of the session and my credit or debit card or checking account will be charged for the time the scholarshipped client has requested to be reserved for them.  I understand that I may not schedule, reschedule, or cancel appointments for other adults. 

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:

Signature arrow
MyCounselor.Online https://mycounselor.online
Signature Certificate
Document name: 3rd Party Financial Responsibility Agreement
lock iconUnique Document ID: b736c9ff8d437ca8da139348e7e16388f1bf7239
Timestamp Audit
November 3, 2020 5:57 am CST3rd Party Financial Responsibility Agreement Uploaded by Josh Spurlock - receptionist@mycounselor.online IP 108.44.223.55
November 3, 2020 6:01 am CST Document owner bobby.oliveri@mycounselor.online has handed over this document to receptionist@mycounselor.online 2020-11-03 06:01:14 - 108.44.223.55