Remote Session Agreement and Billing

I, the undersigned, acknowledge that I understand and agree to the following:

I agree to give you a minimum of 48 hours notice for all cancellations or changes of scheduled appointments. I understand that missing an appointment without prior cancellation or with cancellation less than 48 hours, will be charged to me at the current full rate.

During our session, I will be alone and in a safe environment that is free from outside distractions (e.g. phones, pets, people, etc.) Further, I understand that I cannot record any portion of our session, unless prior arrangements have been made with you.

Additional Conditions: Headphones

I agree to pay you, Carol Benton, C.Ht. the following fee per session. I also agree to pay, in full, for your services on the date of each session.

Billing information and authorization: I give Carol Benton, C.Ht. permission to charge my credit or debit card the fee for each session as detailed above. Any other charges to this account are prohibited, except with approval from me.

Please select card type

Mastercard

Visa

American Express

Expiration Date

CVV

Name (as it appears on billing card)

First Name

Last Name

Billing Address (if different from personal data)

Please check the box below

By checking this box I agree to the terms outlined above.

Remote Session Agreement and Billing

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