Forensic Schedule Fee

  • Ashley Martin, CFMHE, LPC, CRPS, CAMS-II, BCBA,

    Certified Forensic Mental Health Evaluator

  • LOCATION:

    500 W. Lanier Ave., Unit 909, Suite E. Fayetteville, Georgia 30214 P: 770-580-4116 F: 1-888-522-1055 www.clihumanservices.com | info@clihumanservices.com

  • FORENSIC MENTAL HEALTH FEE SCHEDULE AGREEMENT

    As the client, you agree to pay Ashley Martin, CFMHE for her participation in the evaluation process, in providing evaluation, clinical reports, depositions, and/or expert court testimony on my behalf.The Forensic Mental Health Evaluation includes, but is not limited to, comprehensive psychosocial information requiring interview focus on special circumstances to aid in legal/medical/forensic/expert testimony/deposition, review of pertinent data, interviewing collateral contacts, and use of customized computer software designed to detail essential data. Additionally, it may include a report not covered by insurance, containing specialized information pertinent to expert review by attorneys, psychiatrists, mental health professionals, etc. A report is written to qualify expert court testimony and assist against disqualification by the Court.The costs for all clinical services performed, prior to the written report, are to be paid in full, not subject to any contractual agreement with any insurance carrier/provider, in that the services rendered herein are beyond the scope of those services that are normal and customary under such insurance provider contracts.

  • The Costs for Providing Forensic Mental Health Services are as follows:

    (SERVICES ARE ABLE TO BE CONTRACTED AT A FIXED FEE, OR SUBJECT TO COST BELOW)

  • Client Agreement and Contact Information

  • Format: (000) 000-0000.
  • Please select the service(s) in which you are interested in obtaining:

  • Signature Acknowledgments

  • NOTE:

    If depositions are held in the provider’s offices, there shall be a 3-hour minimum.

    A retainer fee of $5,000 will be expected at the initial session, which includes up to 10 hours. This fee is non-refundable, regardless of circumstances. All payments are to be made by check or cash. The remainder of the balance of fees is due prior to the completion of the written report, deposition or trial.


    NOTE:

    Signing of this agreement obligates the signee to accept full responsibility for the above payment.


    MAKE ALL CHECKS OUT TO: Ashley Martin

  • Client Signature Date*
     - -
  • Should be Empty: