This agreement is to serve as a contract for services between the Family Guidance and Therapy Center and

on behalf of

% of assessment fees are presumed to be covered by

after

deductible and / or $

co-payment​ ​per assessment hour has been paid by the “Responsible Party Name” printed above.

We estimate

direct contact hours (testing, interview) and

indirect hours (review of records, scoring, preparation of report).

The responsible party will be charged the remaining balance after the Family Guidance and Therapy Center has received insurance payment. The responsible party is advised to contact their insurance company to verify benefits​.