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Executive Coaching Agreement​

DISCLOSURES & AGREEMENTS
We welcome you as a client and appreciate the opportunity to provide you with professional services. We hope that the following information will answer your questions regarding billing procedures.

E-Sign ACKNOWLEDGEMENT AND AGREEMENT: You agree that your signature for this electronic document is valid and will be enforceable as and to the full extent of a hand-written signature as an original for this entire Executive Coaching Agreement, including all sections and checkboxes here within. BY TYPING YOUR FULL NAME BELOW, you agree to this E-Sign Acknowledgement and Agreement.
CANCELLATION POLICY: Your appointment time is reserved specifically for you. If you are unable to keep your scheduled appointment, or need to reschedule for any reason, please give 24 hours notice. With this notice, we have the opportunity to fill your open session. Without this notice, you will be billed for the session. By CHECKING THE BOX BELOW, I e-sign and acknowledge that I have read and agree to the Cancellation Policy as stated here within.
SELF-PAY AGREEMENT: Payment in full is expected at each session. Statements will be provided to you, at the end of each month, which are suitable to submit to your insurance carrier/employee benefits plan for reimbursement of fees paid. BY CHECKING THE BOX BELOW, I e-sign and acknowledge that I have read and agree to the Self-Pay Agreement.
CONSENT: By signing your name below, you e-sign and agree that all information is yours, true and accurate. You also e-sign and agree to all acknowledgements and agreements within this document (Executive Coaching Agreement). Lastly, you e-sign and consent to services as discussed with your executive coach, including session fees.
CREDIT CARD AUTHORIZATION FORM
*An authorization transaction may be created and then voided when first added to our system.
*Please note that David Pearl, LCSW does not currently accept credit cards at the time of the appointment, but does keep one on file for any late payments.