PRIVATE SELF-PAY FEE SCHEDULE:
Initial Consultation $120
Standard Therapy Session $90
Couples/Family Therapy $120
Supervision for Licensure $60
USE OF INSURANCE: If using insurance, session fees are based on reinbursement rates if applicable, as well as any copay, coinsurance, deductible amounts as specified by insurer. By signing this Payment Policy, the patient/guardian is authorizing the release of information and benefits assignment for claims submitted to insurance companies.
Cancellation Policy: Session fees are generally charged by noon the prior business day of the scheduled appointment. Cancellations must be made before this time and are only waived for (1) hospitalizations/illness verified by a doctor’s note (2) reasonable life events, i.e. death of family member. Late cancellations/no-show fees for insured clients are the equivalent of insurer’s allowable charge and are not reimbursable. Credit Card is generally kept on file, but if opting to pay by cash/check, prepayment is requested before next scheduled appointment. All monies will be refunded if appointment is cancelled in appropriate time. Other services, such as phone consultations over 15 minutes or excessive paperwork will incur additional fees to be discussed in advance with patient. Records requests sent via postal mail can be subject to a $10 charge. Returned check fees are $25.
The provider reserves the right to announce fee increases, which upon effective date may become current for all clients. If payment is missed for any reason, sessions may be postponed until payment is rendered. For verification purposes, please complete this information for the credit card you placed on file at the time of booking or provide information for an alternative card that you wish to keep on file going forward.
* If unable to keep a credit card on file for session fees and late cancellation fees, you may pay your session fees up front by cash or check to be kept on file at all times to cover late cancellations. The payment is fully refundable upon termination of therapy should you not accrue these fees. By signing below, I certify that I have read, understand, agree with this payment policy and authorize the provider to retain my advance payment in the event of a missed or late-cancelled appointment, for any ongoing/regular session for which I do not specify an alternate payment method in advance of the payment deadline, or if my insurer denies payment of a claim for any reason. Additionally, I understand I must replace the extra session fee promptly in the event that I make use of it in order to continue booking sessions.
By checking box below, I certify that I have read, understand, agree with this payment policy and authorize the provider to charge my card in the even of a missed or late-cancelled appointment, for any ongoing/regular session fro which I do not specify an alternate payment method in advance of the payment deadline listed above, or if my insurer denies payment for a claim for any reason.