.HPPGA Sliding Scale Form

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

Sliding Scale Financial Agreement

Name of Client*

First NameLast Name

*Fill in the amount below that our office told you would be your fee.

Initial Evaluation $_____________ (50-60 minute session)*

Individual Therapy $_____________ (50-60 minute session)*

Family Therapy $_____________ (50-60 minute session)*

Initial by each statement.

I agree to pay for each service(s) listed above, in full, at the time that the service is rendered.*

I have read and understand the Billing Policy.*

I have read and understand the Cancellation Policy.*

I understand a credit card is requested to be left on file to recoup monies owed.*

I understand that I must provide one of the following as proof of income or lack thereof: last 2 paycheck stubs, unemployment statement, tax return, or current school semester schedule.*

Sign below*

THERE IS NO PAPER COPY OF THIS DOCUMENT. THIS IS UPLOADED TO OUR HIPAA

COMPLIANT ELECTRONIC HEALTH RECORD.