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SOAR Program Fee Agreement Confirmation

Full Name: Date of birth:

I have reviewed the SOAR Program Fee Agreement completed by my therapist.

I confirm that it is accurate.

The following information is not accurate:

Payer Source Copay Responsibility

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Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

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January 14, 2021 2:50 pm PDT

SOAR Program Fee Agreement Confirmation Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202

January 14, 2021 3:08 pm PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

March 18, 2021 2:57 pm PDT

Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:57:28 - 65.157.96.202

March 18, 2021 2:57 pm PDT

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202

May 27, 2021 9:46 am PDT

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202