285 E. Main St Somerville, NJ 08876
contact@ilcnj.com
(908) 707-0212
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908-707-0212 contact@ilcnj.com

Insurance Changes

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I
, agree that should my insurance cease or change, I am to notify the office administrator before said changes take place. I agree should I fail to notify Inner Light Counseling of these changes, I would be financially liable for all services that have been provided and not covered by my previous insurance at a rate of $100.00 per visit not covered.
Client Signature
Therapist Signature
Date