Declaration of Agreement Regarding Missed or Cancelled Appointments

  • I understand and agree to the following:
    1. It is my responsibility to notify my psychologist, Tanya Mesirow, Psy.D. at her office phone number, (951) 775-4057, 48 hours prior to a scheduled appointment time if I am unable to keep that meeting.
    2. I agree that I will be billed the contracted rate of $150.00 in the event that I miss an appointment or fail to cancel 48 hours prior to my scheduled appointment.
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