Lee Hasty, LCSW , PA
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
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.
Client Name ( print ) Date of Birth
Client / Parent / Legal Guardian Signature Date