3rd Party Financial Responsibility Agreement
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.
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 Authorization: I 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 Authorization: I 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.
Please give the name or names of the individuals being scholarshipped in the field(s) below.
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:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: 3rd Party Financial Responsibility Agreement
Agree & Sign