Cancel the Appointment

For canceling the appointment, we must have 24 hours (1 business day) notice otherwise there will be a charge for Missed Appointment or Late Cancellation, this includes your first appointment.

Once you fill out and submit the form, both the Scheduler and Your Provider will receive this “Cancel the Appointment” Form. Also you will receive a confirmation from your email box.

Cancel the Appointment

Client Name *

Contact Email Address *

Contact Phone *

Cancel Appointment * Cancel the First (Intake) Session Cancel one time appointment Cancel all my appointments Other Cancel Appointment

Need to reschedule? *

YES No, I don't need to reschedule Other Need to reschedule?

Brief Reason Why You Don't Continue Your Sessions *

Your Provider * Jennifer Liu (Neurofeedback) Mark & Danni

Appointment Date *

Appointment Time *

891011121234567 : 0030 AMPM

Additional Information, or reschedule request (If need)

Check to understand the Cancellation: *

If you are unable to keep an appointment, must have 24 hours (1 business day) notice, or you will be charged $100 ($150 for a scheduled Diagnostic Evaluation Session) for the missed session.)

Signature of Client (or personal representative) *

(By typing)

Relationship to Client *

Submit Date: *

Click to select that YELLOW date, it's today's date

By checking this box I certify *

my typed name above bears the same legal authority as handwritten signature.