HPPGA Financial Agreement

Healing Psychotherapy Practices of Georgia, LLC

3750 Palladian Village Dr., Suite 320 Marietta, GA 30066 Tel: 770) 792-0079

Financial Agreement Form
Name*

First NameLast Name
Initial Evaluation $150.00 (50-60 minute session)

Individual Therapy $130.00 (50-60 minute session)

Family Therapy $130.00 (50-60 minute session)

If using insurance, the copay or deductible may be different than above amounts. If, for any reason, your insurance refuses to pay, you will owe the above amount.

Initial and choose applicable statements below.
I agree to pay for each service(s) listed above, in full, at the time that the service is rendered. Fees may be adjusted by the office. I understand this will be discussed with me first.*
I have read and understand the Billing Policy.*
I have read and understand the Cancellation Policy.*
I understand that Healing Psychotherapy Practices of Georgia, LLC requests to keep a credit card or cash on file in order to recoup monies owed.*
I am NOT using insurance to pay for sessions. (type TRUE or FALSE)*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Financial Agreement Form