This authorization form, when completed and returned, gives Your Counselling Ltd. permission to inquire to the below noted insurance company for the purposes of direct billing. By completing the information provided below, Your Counselling Ltd. is permitted to submit insurance claims on my behalf for the purpose of direct billing.

I hereby authorize Your Counselling Ltd. to submit insurance claims on my behalf for the purpose of direct billing. I consent to funds being paid directly to Your Counselling Ltd. for counselling services provided. I understand I am responsible for the full cost of the session if direct billing is not approved, and I will be invoiced for any outstanding balance not covered by my provider. Please note that we cannot guarantee the ability to predetermine coverage as not all providers offer this option. Additionally, coverage may change between the time of predetermination and when the claim is submitted. Coverage may change at any time during your engagement with Your Counselling Ltd.