Statement of Financial Responsibility

Statement of Financial Responsibility

Licensed Marriage and Family Therapist#97197 925-338-7526

Statement of Personal Financial Responsibility

Fees: My fee is $180, based on a 50-minute session for individuals and for couples. If we arrange a longer counseling session, the hourly rate will be prorated to establish your fee. Fees are subject to reasonable periodic increase, not more often than once a 12-month period. I will give you a 1-2 months’ notice prior to making that change.
In the event of telephone counseling that extends beyond 15 minutes, the fee will be prorated based on your standard hourly rate. At some point, you may request my help away from the office (i.e. summary of treatment, assistance with written documents, etc.). Because these special services can be time consuming, we will arrive at a mutually satisfactory fee for each situation.

Payment: Payment is expected at the time of service unless other arrangements have been made. It is not uncommon for clients to request a hold on a check until payday later that week. I am more than willing to do this for you.
As payment, I accept:
• Cash – a receipt can be requested
• Personal checks – made out to “Sumrah Jan”
There will be a $25 service fee charged on the 1st returned check. A 2nd returned check will have a $35 service fee and future payment may be limited to cash only.
• Credit Cards (via Ivy Pay) – ALL clients will be required to have a credit card on file, which may be charged as per the request of the client, or in the event of “no shows” or last- minute cancelation which are less than 24 hours in advance.

There might be a time when you forget to bring payment. I will request that you drop off payment before your next scheduled session. Please be courteous that my income comes from my practice. If payment is not received for services rendered, I reserve the right to not schedule another appointment until your account is brought current.

Insurance Reimbursement:
If you have a health insurance policy, it may provide some coverage for your treatment. I will provide you with whatever assistance I can in helping you receive the benefits to which you are entitled, however, you (not the insurance company) are responsible for full payment of session fees. It is very important that you clarify what mental health services your insurance policy covers. It should be understood that insurance companies and managed care organizations often require information about your treatment. You should be aware of what confidentiality you may have waived when you enrolled with them.
Payment Past Due
If payment is past due for over 30 days, I may choose to submit your name and amount owed to a collection agency. I may also choose to take you to small claims court. A 3% interest rate will be applied to all balances that are 30 days overdue. If you have concerns or questions about payment and fees, I encourage you to discuss them with me. My policies are well defined because I love my job, and do not want to be a bill collector. Your understanding is much appreciated.
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