REQUEST A SESSION
NOTICE OF PRIVATE PRIVACY
This form allows The Mental Haven (TMH) to have a card on file if you are a no-show for a session or want to reschedule/cancel within 48 hours of your session or do not pay your balance. You will be charged a $65 fee if you reschedule after 48 hours, but before 6 hours of your session. Any rescheduling within 6 hours of your session incurs an $85 fee. The no-show fee is $85. You incur this fee if you do not attend your session within the first 15 minutes. We will never share your card information with anyone outside the practice or its owners. Your card will only be charged manually if we are charging the fee or if you have asked us to. Your card will not be charged or used otherwise. If you decide to end your services with TMH, or your case is closed (meaning we have stopped hearing from you after three attempts of reaching out), we will delete your card information from our files. If you decide to come back to TMH, we will ask for this information again. Please note that if your card declines when attempting to collect the fee, your services will be placed on hold until we can retrieve it.
***Please let us know if you have any issues with the form!