CLIENT PAYMENT AGREEMENT
By paying online or in person you are fully aware of the terms and conditions as well as the client payment agreement which is as followed:
1. I agree that this service/product/experience is not covered by any type of health insurance
2. I agree that i am not under financial duress and therefore, unable to afford this service/product/ experience
3. I understand that no billing will be provided on the services performed/product or experienced purchased (Payment is due in FULL at time of purchase/reservation)
TERMS AND CONDITIONS FOR ONE-TIME CHARGE OR DEBIT: I hereby authorize Truth Healing Evolution Counseling to initiate a charge or debit entry on my credit card, debit card or checking account (as applicable) in an amount equal to the amount I entered on the payment entry screen. This authorization will remain in full force and effect until the transaction has been processed and the funds have been transferred to and received by Truth Healing Evolution Counseling or until I terminate this authorization in writing by providing the above named provider with a written notice, at least 72 hours prior to my scheduled payment, of the termination of this authorization signed by me. I agree to maintain an available balance sufficient to pay all authorized payments, and agree that Truth Healing Evolution Counseling is not liable for any overdraft or insufficient balance situation or charge (including, but not limited to, finance charges, late fees or similar charges) caused by my failure to maintain a balance sufficient to pay all payments issued through this payment plan. I further agree that the named behavioral health & wellness provider may charge a reasonable service fee for any charge or debit transactions that result in a returned debit entry, including, but not limited to, returns resulting from insufficient available balance in my account, closure of my account or incorrect account or routing information provided by me. Said fee shall not exceed thirty-five dollars ($35.00). I agree to promptly notify Truth Healing Evolution Counseling in writing of any changes to the financial institution account information and hereby grant authority for Truth Healing Evolution Counseling to charge or debit such changed account. I agree that Truth Healing Evolution Counseling will not be responsible for any expense that I may incur from exceeding my credit limit or overdraft of my account as a result of a charge or debit made pursuant to this payment plan.
PLEASE NOTE: Any changes to the authorized payment must be made at least 72 hours prior to the scheduled date by contacting via email at HR.firstname.lastname@example.org. If this authorization was provided in error, please email us at HR.email@example.com immediately. By making a payment i, hereby declare under penalties of perjury, that i have read and understood the information in this consent, and agree to the terms and conditions stated above.
Wendy’s Life Wellness (WLW) HEALING HOUSE
Home of: Truth Healing & Evolution Counseling, iLove Me ExperienceTM & My Warrior Life
1060 E. Foothill Blvd Suite 204 Upland Ca 91786 www.WendysLifeWellness.Com HR.firstname.lastname@example.org