Policy Agreement

Standard rates

Treatment session $195

Initial Evaluation $497

I understand that treatment sessions are 45 minutes in duration. Evaluation sessions are up to 60 minutes in duration.

Payment Policy

Payments are due in full prior to the scheduled appointment time. Payments are accepted via Venmo @Christine-SofianeKatzenmaier, or Zelle (christine@speechandvoiceworks.com), or via credit card directly through the scheduling calendar. https://www.speechandvoiceworks.com/schedule-appointment.

Additional charges

I understand that any additional reports I request (e.g.. progress reports, additional insurance documentation) will be charged accordingly, subject to additional rush fees if the reports are required in advance of the standard two week turnaround time. I further agree that any professional time (i.e. related conference calls, etc.) necessary for treatments is billable at regular session rate.

Cancellation, Tardiness and No-Show Policy

If I must cancel an appointment for any reason other than sickness, I agree to give Speech & Voice Works a minimum of 48 hours notice. If I am (or my child) sick, I agree to cancel my appointment via telephone call no later than 7:30am of the day of the appointment. Should I fail to adhere to this policy, I understand that I will be billed the usual hourly rate. It is further agreed that my therapist will wait 15 minutes for my arrival, after which I am considered a no-show and subject to the full cost of the scheduled appointment.

Disclosure Requirement

I agree to disclose in writing below all of the known physical and medical conditions of myself (or child). I agree to release and hold Christine Sofiane Katzenmaier MS CCC-SLP, and Speech & Voice Works harmless from any liability, claims or inquires.

Name (person receiving services)

Diagnosis and Date of Diagnosis

Date of Birth

YYYY

Physician, ENT or Pediatrician

Physician's Contact Number

(###)

###

####

Known Medical History, Physical or Medical Conditions

Previous Tests Given & Dates

Contact Information

Name (if child, please fill in information of both parents)

First Name

Last Name

First Name

Last Name

Email 1

Email 2

Phone 1

(###)

###

####

Phone 2

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I have read and agree to the above policies written for speech-language pathologist, Christine Sofiane Katzenmaier, MS CCC-SLP, CA Lic# 22204, Speech & Voice Works.

Patient Name (if child, parent/guardian name)

Date

YYYY