Cancellation Policy

 Cheryl A. Byk, LCSW & Counseling Associates 

 500 North Main St. Lanoka Harbor, NJ 08734                   Fax (609) 242-3207     

     CANCELLATION POLICY  In order to meet the increasing mental health needs of our community, we have adapted the following policy to eliminate chronic no shows, and/or late cancellations. Therefore, it is the policy of this practice that you provide a cancellation a minimum of 24 hours in advance of your scheduled appointment. If you do not provide the required notification, you will be charged the full fee for the session. (Copay and Insurance Reimbursement)  Initial Session: Upon completion of your intake, you will receive our Welcome Letter along with a copy of our Cancellation Policy. We request that you confirm your appointment no later than 48 hours in advance. In addition, the attached Cancellation Policy will need to be completed and returned at time of confirmation. If you do not confirm your initial appointment, you will be removed from the schedule. If you do not provide a minimum of 24 hours notice of cancellation, or do not show for your initial appointment you will be charged the full fee for the session.  Subsequent Sessions: For ongoing sessions, you are required to provide a minimum of 24 hours notice of cancellation regardless of whether or not a courtesy confirmation call was received from our office.  If you will be late for an appointment, please notify the office ahead of time.  After 15 minutes, this will be considered a No Show and you will be charged for a Missed Appointment. Your credit card will be charged the full fee for the session.  Insurance coverage is not a guarantee of payment. If your insurance company denies a claim for any reason, you will be responsible for the full cost of those services. If you elect to process your own insurance claim(s), you are aware that you are responsible for payment in full at the time of service. Monthly statements will be provided for any balance due after processing by the insurance company. Any outstanding balance over 30 days will be charged to your credit card.  

I have read the above policy regarding my financial responsibilities to the practice of Cheryl A. Byk, LCSW, LLC. I agree to pay the full amount of all outstanding balances for the provision of mental health services. My signature authorizes Cheryl A. Byk, LCSW, LLC to charge my credit card for cancellation of sessions not honoring the minimum 24 hour cancellation policy, missed appointments and any outstanding balances on my account. I acknowledge there will be a $3.00 Service Transaction Fee each time my card is utilized.  I authorize and guarantee payment for any services rendered made with my credit card. This authorization is valid until I provide you with written cancellation. 

 Client Name ( Print)__________________________ Client Signature_____________________ __________                                    

 Date  __________________________     Parent/Guardian (Print)_______________   Parent/Guardian Signature_____________________    

Date ____________________________

Card Type: Visa American Express Mastercard  Card 

Number: ______________________________________________________  Name of Bank: _____________________________________________________  

Expiration Date: ______________      Security Code (CVV): ________________

 Name as it appears on credit card: ______________________________________        

  (Print) _________________________________ ___________________       Authorized Signature of Cardholder   


 Address (where credit card bills are sent): _________________________________________________________________  _________________________________________________________________

Client Satisfaction Survey

We appreciate your willingness to take the time to complete the following survey. It should only take about 5 minutes and all of the information is confidential. Your feedback is crucial in our efforts to maintain excellence in client satisfaction.

When did you first call the office for an appointment?    

 Weekday 8:00 am - 5:00 pm    

Weekday 5:00 pm - 8:00 am   

 Weekend Saturday/Sunday

Timeliness in the office staff answering your call     

Poor  Fair    Good    Very Good    Excellent   

Knowledge and helpfulness of the person you initially spoke with 

Poor    Fair    Good    Very Good    Excellent

Timeliness in the information you received regarding your initial session  

  Poor    Fair    Good    Very Good    Excellent

How would you rate the service you received in scheduling your appointment? 

 Poor    Fair    Good    Very Good    Excellent

Convenience of your counselor's office hours   

  Poor    Fair    Good    Very Good    Excellent

Ability to schedule an appointment at a convenient time  

   Poor    Fair    Good    Very Good    Excellent

How well your counselor listened and understood your concerns 

    Poor    Fair    Good    Very Good    Excellent

How would you rate the service you received from your counselor?  

  Poor    Fair    Good    Very Good    Excellent

Satisfaction with the amount of time you had to wait for your follow-up visit

  Poor    Fair    Good    Very Good    Excellent

How would you rate the overall service you received from the practice?     Poor    Fair    Good    Very Good    Excellent

Overall how did the services you received from your counselor help you deal more effectively with your concerns?    Poor    Fair    Good    

Very Good    Excellent

Would you recommend this office to others in need of counseling services? 

   Yes    No

Convenience of office location  

   Poor    Fair    Good    Very Good    Excellent