I acknowledge that I am financially responsible for psychotherapy services provided by A Life Worth Living 365. I understand that my card on file will be used for payment of psychotherapy services, in addition to any fees associated with cancellations and no shows (See ‘Informed Consent’). I also agree that if my account is referred to a third party for 60 days past due, I will be responsible for the collection agency fee plus interest and the balance due. You agree, in order for us to service your account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide us. Methods of contact may include using pre-recorded or artificial voice messages and/or the use of an automatic dialing device, as applicable. I/We have read this disclosure and agree that Krystyl Wright, LCSW or a A Life Worth Living 365 representative may contact me/us as described above.