Voucher Invoice Submission

Therapy Fund Foundation – Voucher Invoice Submission

Use this form to submit invoices for Therapy Fund Foundation voucher services. Submit a separate form for each client/voucher. You may include multiple dates of service for the same client. Invoices must include the voucher number, client name, dates of service, rate, and total amount requested. Do not include psychotherapy notes or clinical details.
Provider Information
Provider Name

First NameLast Name
Provider Email
example@example.com
Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Services
Which funding category applies to this client?
Service delivery method
Does the client have insurance?
Voucher & Payment Information
Use only approved rates. The standard Therapy Fund rate is up to $130 per counseling hour unless Therapy Fund Foundation has provided written authorization. DEEL counseling rates may not exceed $200 per counseling hour unless Therapy Fund Foundation has provided written authorization.
Voucher number
Date of Service Client was seen

MonthDayYear
What is your individual hourly rate?
Amount to be paid
Up to $130 for regular vouchers and up to $200 for DEEL vouchers
Payment method
Please provide the email address associated with your PayPal account for payment, or a link to an online payment portal where we can pay by debit card (such as Square)
Upload Invoice (That includes voucher #, client name, and date of service)

Your client signed a waiver for privacy when signing up to allow their name to be included on billing invoices.
Cancelof
Certifications
I certify under penalty of perjury that...
I certify under penalty of perjury that the information provided in this invoice is true and accurate; that the services listed were provided as stated; that these services have not been billed to insurance or paid by another source; that the amount charged to Therapy Fund Foundation is consistent with or less than my ordinary rate and does not exceed the approved voucher rate; and that I am authorized to submit this invoice. I understand that incomplete or inaccurate submissions may delay payment.
Signature
Date signed

MonthDayYear
Date
Should be Empty:

Therapy Fund Foundation – Voucher Invoice Submission

Provider Information

Services

Voucher & Payment Information

Certifications