FEE AGREEMENT AND FINANCIAL POLICY

Thank you for choosing Aspire Counseling Services, LLC. Please review this Fee Agreement and Financial Policy with regards to private pay and couples counseling.

PRIVATE PAY (NOT USING INSURANCE PAYMENT)

Private payers are expected to pay the sum of session #1 before a 3rd session will be scheduled. After first payment, private payers are expected to pay for a session per each 2 scheduled sessions. Therefore 1:2 ratio.

Individual sessions are billed at a rate of $135/session, unless otherwise agreed upon________.

 

 

FAMILY/COUPLES COUNSELING FEES

Couples counseling isn’t typically covered by insurance. In addition to the charged individual session fee, including couples counseling session fees not covered by insurance for individual sessions, will be collected as an automatic $25 additional fee.   Session #1 fees must be paid before a 3rd session will be scheduled. After first payment, couples are expected to pay the sum of 1 couples session fees per each 2 scheduled sessions. Therefore 1:2 ratio.

Couples sessions are billed at a rate of $145/session.

 

 

I will self-pay for services at Aspire Counseling Services, LLC. I agree to the fee schedule in this document. I understand payment is due at the time described in this agreement.

Client name:____________________________________

Client/Guardian signature:_________________________