Page 123 - Meeting with Children Manual
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Agreement to Mediate/Informed Consent Page 7
Credit Card Information
Name: Number:
Expiry date:
Signature:
PAYMENT PLAN:
___ 50/50 Sharing plan ___One party pays for the Service
___Proportionate to Income ___Other
DATE OF CONTRACT
This contract shall become effective on ____________________________________
______________________________________
Name (Parent) print and sign
Name (Parent) print and sign
Dr. Lorri Yasenik (Mediator)
July 29, 2014
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