The London Association for Counselling & Psychotherapy

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This form is for use in setting up a recurring appointment series, and for letting lacap know what basis to use for payment receipt responsibility. It will be actioned by the administrator

Your Name?

Please fill in the patient's name & email address:Patients Name:

The email address is:

What referral fee basis do you want? Formula 1 - I will pay the full fee taken for the 1st six sessions

Formula 2 - I will pay 23% of the session fees taken for the 1st thirty five sessions

Not in referral fee period

Please tell us about what kind of sessions you want to setup for this patient?Regular Recurring Meetings; the next meeting will be the first one Regular Recurring Meetings; but the next session will be a one-off
The time & date of that next meeting will be:

What Room?

The Recurring Appointment Series► the appointment(s) occurs on the same day every week (or every other week or less)

► the appointment occurs in the same week of every month (or other month)

If ►then Occurs on the same day(s) in the week

Twice Weekly? Once weekly or less Twice weekly	For once weekly or less: (or the first session in the week - twice weekly

	ONLY IF TWICE-WEEKLY - Complete for the second session

from this start date

If ►then Occurs in the same week per month

This appointment recurs on the of every at :
from this start date

	60 minutes
	45 minutes

Session Length?

Time Limited Contract?

	Open Ended Work
	The contract is time-limited
	Number of sessions to book in

Select oneAdd a note of my cancellation policy to all emails

Don't do that

Put your note on the sessions confirmation? Yes No

That note - do you want it repeated? No, only this first email

Yes please, repeat it on all emails

I have discussed fees. I would like this patient to pay my fees..... per session, either before or after the meeting as preferred

per session after the meeting

per session before the meeting

monthly in advance (on the 1st session of the month)

Other

Declaration of Receipt Responsibility: I would like this patient to pay......Always by Card or Cheque to Reception

By Postal Order to Reception

I will always receive payment for this patient. Reception is not to bother them about this.

Thank you.
You have completed the information I need to set up your appointments for this patient.

Do you want to submit this now?

09/02/2009 14:23:05