Agreement form

Social Skills Groups – 60 Min Group
Group Session Fees: $995  for ten 60 minute group sessions and one 60 minute parent session. Payable in 10 weekly $80 payments and one $195 parent/guardian session.

Cancellation Policy: Consistent attendance is extremely important for your child to obtain maximum benefits from a group. In addition, consistent attendance for all participants is crucial for group cohesion. We understand most children miss at least one group for various reasons. Therefore, each participant will be allowed to miss one group of their choice. There will be no charge for this one missed group.

You will be financially responsible for all other group sessions, regardless of attendance. Please make every effort to have your child attend every session. If your child is unable to attend a session, please notify me as soon as possible by leaving me a voicemail at 732-380-1575 ext. 306.

Terms and Conditions
  • I understand that I am financially responsible for all sessions, except for the one allowable missed session, even if my child is unable to attend.
  • I understand that I am financially responsible for the $195 parent/guardian session towards the end of the group, even if I choose not to attend.
  • All payments are due at the time of each session unless other arrangements are made in advance.
  • I understand that my “Out of Network” insurance is accepted and submitted as a courtesy. Should my insurance fail to reimburse for services rendered, I understand I will be financially responsible for any unpaid balance.
  • I understand it is my responsibility to be aware of my insurance benefits (e.g.-maximum benefits per year).
  • I understand and agree that Lighthouse Counseling & Sand Play Training Center will bill fees for services directly to my insurance company.
  • Any account balance not paid in full within 45 days of statement due date will be assessed a $30 service fee and assigned for legal recovery with I.C. Systems, a professional collection agency.
  • Should my unpaid account be assigned for legal collection, I understand that I will be responsible for all collection costs, which includes the original debt owed, collections charge of 30% of balance, penalty interest accrual rate of 16% (per applicable NJ Law) and any other legal fees incurred in relation to recovery of outstanding balances.

I have read and understand the payment policy and agree to abide by its guidelines.

  • DD slash MM slash YYYY
  • Please type your name in the first set of boxes and the date in the second. Use your mouse to sign in the signature box. Click the submit box, which will email this document back to me. By doing so, this will act as your signature, therefore validating this agreement. If you are unable to email to me for some reason, please print and sign this document, and bring it with you on the first day of group.

Please type your name in the first set of boxes and the date in the second. Use your mouse to sign in the signature box. Click the submit box, which will email this document back to me. By doing so, this will act as your signature, therefore validating this agreement. If you are unable to email to me for some reason, please print and sign this document, and bring it with you on the first day of group.

You have the option to pay in full, or in weekly payments. I will leave a basket at the front desk, please place your check or cash in it for weekly payments. It is time-consuming to swipe multiple cards before or after group. If you wish to pay by credit card, please either pay in full or sign our agreement authorizing weekly payments to be
made.

Now, or throughout the duration of group, if you have any questions or concerns, please feel free to contact me either by telephone 732-380-1575 ext. 306 or email, tzachos_kaplan@lcsnj.com.

I look forward to working with your child and family.

Thank you,
Toni Zachos-Kaplan

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