Contract for Negotiated Fee

Contract for Negotiated Fee for Therapy Services

CONFIDENTIAL

The standard rate for therapy sessions at The Peacemaker Center is $165 per fifty-minute session.

For those in need, The Peacemaker Center may offer a reduced fee on a first come, first served basis, which is limited to 10 sessions, followed by re-evaluation.

By signing below, we agree:

Given my financial situation, I have agreed that I will pay the fee listed below for each session for the first 10 sessions. After every 10 sessions, the fee will increase by an additional $5. Once the fee reaches $70 per session, the fee will increase by a minimum of $5-$10 yearly.

Last minute cancellations (less than 24 hours) and "No Shows" will be charged the agreed upon rate, unless waived by the therapists in the case of unexpected emergencies and illnesses.

If you are not able to pay the fee at each session, only one follow-up session will be scheduled until payment is received.

I further understand that:

I may decrease the number of sessions per month (thus bringing down the monthly cost).

I may switch to a master's level intern, when available, for quality counseling at a reduced rate.

Negotiated Fee

Negotiated Fee Summary: Fee for services as agreed by therapist and client listed

Therapist Name*

Session Fee for 1st 10 Sessions:*

As the client, I am responsible for:

My church / organization has agreed to pay:

My parent/guardian will pay:

Signatures

We understand the above guidelines and agree to the the listed per session fee:

Date

Client Name*

First NameMiddle InitialLast Name

Client's Birth Date*

Date

Client's Age*

Parent or Legal Guardian name - if client under age 14

Client Signature - if client is age 14 or older

Sign with your mouse, stylus, or finger

Signature of Parent/Guardian - if client is under age 14

Sign with your mouse, stylus, or finger