Hollis J. Nemiroff, Ed.S., L.P.C.
2275 Whitehorse Mercerville Rd, #9
Hamilton Twp, NJ 08619
Agreement to Pay for Professional Services
I request that Hollis Nemiroff provide counseling services to me and I agree to pay the fee of $125 per session at the time of the session, or a fee of $50 for late cancellation (less than 24-hour notice) or no-show session.
I understand and agree that I am responsible for the charges for services provided by this counselor, although other parties may reimburse me for payments made.
I agree to pay for services provided until we end the counseling relationship.
I have read the Informed Consent and I understand it and agree to its terms.
I have provided my credit card information (below) and I authorize per session charges with this signature on file for missed sessions at the rate of $50 per late cancel or no-show session. If my credit card expires during the course of treatment, I will update information for this agreement. If my credit card is rejected, I will be responsible for the charge and any additional penalties incurred as a result of the rejected credit card.
Please download and fill out the Payment Agreement Form and attach it to the following submission form.