I have decided to participate in therapeutic services as a private pay client.
I understand that that I am fully responsible to pay the Therapists full rate as
well as any fees charged for late cancellations and no shows for
I have made my therapist aware that I do not wish to bill my insurance at
this time for therapy services.
I have agreed to let my therapist know if anything changes with my status. I
will notify Therapist if I obtain alternative insurance at a later date and
decide that I would like my sessions billed to my insurance.
I understand that if I choose to acquire insurance my therapist is not liable
and is not obligated to reimburse previous sessions where I have chosen to
opt out of billing my insurance. My opt in to use insurance will start from
the day I notify my therapist of the change and cannot be backdated to
I understand that if I obtain insurance, I cannot use the payment of sessions
towards my deductible without first communicating this to Therapist.
Rates for Services:
Initial Intake Assessment: $130 per session
Individual Outpatient Therapy (53 Min and Over): $105 per session
Family/Couples Thearpy (53 Min and Over): $115 per session
Any phone conversation over 10 minutes will be charged at a prorated fee based on $60/hour
Cancellations are required 24 hours in advance. Any appointments scheduled but not kept, as well as any appointments cancelled within 24 hours of scheduled time will be charged $75. We ask that you give at least 24 hours' notice if you need to cancel or reschedule your appointment due to your (or your child's) illness. If you have a contagious illness (or if your child has a contagious illness and you are not able to find child care), we ask that you do not come to your appointment. Video conferencing through a HIPAA-compliant platform is available if you are not able to come to the office.