Policies and Fees:
At this time, I am not on insurance panels, but am happy to provide you with a bill that you can submit yourself for reimbursement. Please be aware that insurance companies require some disclosure of personal information and a diagnosis. Your signature below represents your consent and agreement for release of this information.
Fees are due at the time of service (payable with either cash, check or credit card). If you need to cancel, please notify me as soon as possible. If the appointment is missed or cancelled less than 24 hours in advance you will be responsible for the full fee. A $30 service fee will be charged for any returned checks.
My fee is normally $120 / hour but in order to make counseling affordable to more people I have the following sliding scare for those requesting cost relief based on family income:
$0 – 60,000: $60 / hour
$60,001 – 85,000: $80 / hour
$85,000 – 100,000: $100 / hour
$100,000 and above: $120 / hour
I _____________________________________________ have read and understand the above information. I understand that the agreed upon fee of _____________________ is due at the end of each session and also understand the cancellation policies.
Witness signature: _____________________________________________