Celebration Counseling

Fee Schedule and Policies

Fees: My fee is $120.00 per session. Sessions are 50 minutes in length. In some circumstances a reduced fee can be arranged for clients in particular circumstances. In addition to weekly appointments, it is my practice to charge this amount on a prorated basis for other professional services you may require of me, such as report writing, telephone conversations, or consultations with other professionals. It is the policy of this office to request payment at the time services are provided unless other arrangements are made in advance.

Health Insurance & Confidentiality of Records: Since disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims, Celebration Counseling does not accept insurance payments. Celebration Counseling has no control or knowledge over what insurance companies do with the information submitted or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information is entered into insurance companies' computers and soon will also be reported to the, congress-approved, National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question, as computers are inherently vulnerable to break-ins and unauthorized access. Medical data has been reported to have been sold, stolen, or accessed by enforcement agencies; therefore, you are in a vulnerable position.

Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on the therapists of Celebration Counseling to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

Cancellation: When an appointment is made, that time is reserved exclusively for you. A 24 hour notice is required for cancellation without charge. A charge of $60.00 is made for late cancellations and missed appointments. Insurance carriers do not pay for missed appointments.

In signing this form, you are indicating your understanding and consent to all of the above. Additionally, you agree to hold harmless this office regarding any claim made against unpaid fees. It is the policy of this office to send to a collection agency or file in small claims court for any unpaid fees.

This office reserves the right to institute an interest charge of one percent per month (or as allowed by law) for fees unpaid for an extended period, with timely notice given to you so that the problem may be corrected before interest charges are applied.

As with any issue which may present itself, you should feel free to discuss with me any questions that arise regarding fee policies. I understand that there are times when difficulty with finances may temporarily prevent you from meeting your obligation under this contract. Should such a circumstance present itself, please contact this office at once so that we may make appropriate arrangements.

Client Name: _______________________________________________________

Client Signature: ____________________________________________________

Date: _____________