This agreement is between the undersigned Responsible Party on behalf of the Client identified herein, and Quality Telepractice, LLC. This agreement is in effect as long as the Client is enrolled in sessions provided by Quality Telepractice, LLC. I understand the following Policies:

• Sessions are paid by the month, with payments for all sessions in that month paid for in advance, securely on the Quality Telepractice website. Monthly session fees are due 24 hours prior to the first session of that month. For partial months, the remainder of all sessions in that month are due 24 hours prior to the first session of that month. No refunds or exceptions to this payment policy.

• If payment is not received 24 hours in advance of the Client's first session, the Responsible Party will receive a written warning by email with notice to pay before the session. If payment for the month is not received by 24 hours in advance of the second session of the month, the Responsible Party will receive a second warning by email with final notice to pay before the second session. After two unpaid sessions, the Client will be discharged from Quality Telepractice. At that time, the Responsible Party has one month to pay for the two missed sessions or the account will be sent to collections.

• To cancel or reschedule a session, the Responsible Party must notify Dr. Debra Edgar 24 hours BEFORE the normally scheduled session. After that time the instructor loses the opportunity to schedule another student in the time slot and the Responsible Party will be charged for that session.

• If the Client does not show up for a session, or the Responsible Party fails to provide proper advance notice of cancellation, the account will be charged.

• 24 hour notice of any cancellations or schedule changes must be sent directly to Dr. Edgar by text at 407-928-9582 or by email to: dr.edgar@qualitytelepractice.com.

• The Client is not required to continue sessions beyond the month which has been paid, however if the Responsible Party cancels before the end of the month, no refunds will be issued. There are NO time commitments beyond each month for which payment is made. The Responsible Party should provide two weeks notice if they need to permanently cancel.

• Memory Care services do not require any additional materials or fees.

• Tutoring may require materials such as books or instrument accessories to be purchased.

*Services rendered by Quality Telepractice, LLC are considered memory coaching and are provided by trained and independent memory coaches specializing in facilitating memory exercises that have proven to be beneficial in maintaining memory function. The services are not considered to be Speech-Language Pathologist services for cognitive care as outlined in Medicare and medical billing codes, and as such may not be billed to or reimbursed from, Medicare or private health insurance providers. The client understands the payment for the services is the sole responsibility of the client and that Quality Telepractice LLC may not bill Medicare or private health insurance providers for the services on behalf of the client, and the client may not request reimbursement for the services from Medicare or private health insurance providers.

By checking this box and digitally signing below, I acknowledge that I have read, understand, and agree to abide by all policies contained herein, and provide my informed consent for the delivery of services through telepractice.

By checking this box and digitally signing below, I hereby grant permission to Quality Telepractice, LLC to observe as needed and to video/audio record clinical sessions for the purpose of evaluation and treatment for:
Printed Name of Client:

Printed Name of Responsible Party:

Today's Date:

Your Email:

Your Phone Number:

Signature: