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, 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 number of sessions indicated below.
- 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*
# of 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

MonthDayYear
Date
Client Name*

First NameMiddle InitialLast Name
Client's Birth Date*

MonthDayYear
Date
Client's Age*
Parent or Legal Guardian name - if client under age 14
Client Signature - if client is age 14 or older

Clear
Sign with your mouse, stylus, or finger
Signature of Parent/Guardian - if client is under age 14

Clear
Sign with your mouse, stylus, or finger
Should be Empty:

Negotiated Fee

Signatures