Statement of Personal Financial Responsibility
Fees
Feesare paid at the beginning of each session. According to our agreement, my fee is $120 per fifty-minute session. If counseling sessions differ from the fifty-minute session, the hourly rate is prorated to establish your fee. Appointment times that are shorter or longer than fifty minutes should be arranged in advance.
If you are paying a reduced rate (anything under $120 per session), I will revisit that fee base with you upon moving sessions from weekly to every other week.
Occasionally you may have a session where you want more counseling time. I will alert you if we are likely to run over your scheduled time so that you can make that choice when available. We will periodically assess the progress of counseling in 6 week intervals, or as either of us recognizes the need to do so. In the event of telephone counseling, my fee will be based on my standard hourly rate.
You may on occasion request my help away from the office (i.e. court appearances, home visits, school observation, summary of treatment, etc). Additionally there may be times when you will need assistance with written documents. Because these special services can be time consuming, we will arrive at a mutually satisfactory fee for each situation.
Payment
Payment is expected at time of service unless other arrangements have been made. If I am seeing your child, please have the child bring the payment in with them at the beginning of the session. It is not uncommon for clients to ask me to hold a check until payday later that week. I will gladly do this for you.
As payment for your sessions I accept:
* Cash
* Personal checks- When paying with a check, please make out the check in advance so as not to use your counseling time.
There will be a $15 service fee charged on the 1st returned check. A 2nd returned check might limit your payment options to cash only. There may be a time when you forget your checkbook. I ask that you please drop a check in the mail within one business day. I will schedule a future appointment for you based on receiving the check within 3 business days. If payment is not received for services rendered, I will not schedule another appointment until your account is brought current.
Paying for Other’s Treatment
If you are financially responsible for paying for treatment for your child/spouse/parent etc., and you decide to stop paying for treatment, you will need to communicate this to me one week prior to my next session with this client. This will allow me to speak with the client regarding other payment arrangements. If you do not advise me of this change within one week, you will be financially responsible for that session.
Being Courteous
I ask you to please keep in mind, that while I am in the “helping profession,” this is a business. As with any other health professional (Medical Doctor, Dentist, Chiropractor, etc), I expect payment at time of service. Please do not wait to tell me that you cannot pay for your session until the end of that session. My livelihood, just as anyone else’s, relies on income. My income comes from my practice. I appreciate you being considerate and paying me at time of service, unless other arrangements are made in advance. I ask that you drop off a check in the drop box outside my office if you have forgotten your checkbook. I reserve the right to cancel your appointment if I have not received payment 72 hours before your next scheduled appointment.
Payment Past Due
If payment is past due for over 30 days, I may chose to submit your name and amount owed to a collection agency. I may also choose to take you to small claims court. A 3% interest rate will be applied to all balances that are 30 days overdue.
My policies are curt and precise because I enjoy being a therapist so much more than a bill collector. I appreciate your understanding.
I have read and understand the Statement of Personal Financial Responsibility
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