Office Policies
                                                     Lee Hasty, LCSW , PA

Cancellation Policy
  I understand that – except for illness – I’m required to give a 24 hour notice for cancelling an
appointment. Failure to do this or not showing for an appointment will result in me being billed for the
session. I understand that my insurance cannot be charged for late cancellations or missed

Property Damage
  I understand that I will be billed for any property damage that I incur or is incurred by a family
member or guest of mine in this office. I understand that I will be billed $500.00 if I, a family member,
or a guest of mine pulls the fire alarm resulting in a false alarm.

  I’m available for emergencies only on my cell phone at 704-254-1688. Should you have a life-
threatening emergency call me immediately or go immediately to your nearest emergency room or
call 911. Non-emergency or routine phone calls should be made to the office number at 704-283-
2900. Routine calls will be returned within 24 hours.

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Client Name ( print )                                                                         Date of Birth

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Client / Parent / Legal Guardian Signature                                           Date