Missed Appointment Agreement Form

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This form is part of the Client Intake Packet. It was last updated May 17, 2021.

Innovative Counseling & Consulting, Inc.

Missed Appointment Agreement

Innovative Counseling & Consulting Inc. recognizes the importance of consistency within the treatment setting and the overall progress for the client. Therefore, missed appointments are a concern as they interfere with progress within the treatment setting.

Instructions: Please enter your initials in the field following each statement to acknowledge and agree to the terms.

Part I: The Terms

The following protocol will be followed for all missed appointments (All steps will be
documented in the clients file):

1. For the 1st missed appointment: a telephone call will be made in an attempt to contact the client and reschedule the appointment.

2. For the 2nd missed appointment: a telephone call will be made in an attempt to contact the client and reschedule the appointment.

3. For the 3rd missed appointment: a telephone call will be made in an attempt to contact the client and reschedule the appointment; and a letter will be mailed to the client in an attempt to reschedule the missed appointment.

4. If missed appointments continue, the client may be discharged from services due to the lack of benefit on the client’s part. Prior to any discharge, the program supervisor will review each individual circumstances and all documentation to deem discharge as the appropriate course of action. Discharge from services for the client is the last resort of action, and will only occur after the provider has followed the procedure set by this action, and will only occur after the provider has followed the procedure set by this policy with client, their guardian, and/or their legal representative.

5. If there are circumstances that interfere with the client attending and participating with services, then a plan will be put in place with the collaboration of the client and their support system to help resolve the barriers leading to the attendance issue.

Part II: Signature

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