Psychotherapy Financial Agreement

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Ray of Hope Child Therapy Services Inc

533 Airport Blvd. #400

Burlingame, CA 94010

877-758-7257

contact@turajohnsonmft.com

Email *

Client Name *

I agree that the full fee for sessions are as follows:

Tura Johnson LMFT-$190 (individual) and $220 (families);

Coreen Beasley LMFT-$150 (Individual) and $180 (couples/families);

Malia Green AMFT-$100 (individual) and $120 (families/couples);

My sessions will last 45-50 minutes. I am aware that any cancellations of appointments must be made more than 48 hours before my appointment, unless it is an emergency and if I do not cancel or not show up, I will be charged for the full fee of that appointment. I agree to be financially responsible for the cost of treatment and maintain a credit card on file. I am aware that if I have not paid for services received or worked out a payment arrangement treatment may be discontinued.

One of the following will apply to you: *

I am paying full fee for psychotherapy. A super bill will be provided for reimbursement purposes

I am electing to have my treatment to be paid in full or part by my insurance carrier or another third party, I will authorize this in writing and allow Ray of Hope Child Therapy Services Inc to release to an authorized agent of my insurance or a third-party payer information about the type(s), cost(s), date(s) of any service of treatment I receive. I am financially responsible for any portion of the fees not covered or reimbursed by my health insurance carrier. Further, I understand that I am responsible for preauthorizing sessions before beginning treatment and if I do not receive preauthorization, I am financially responsible for those sessions not covered by my insurance.

I have health insurance but do not want my insurance billed and instead want to pay full fee/out of pocket. I understand that Ray of Hope will not “back bill” my insurance company or provide superbill for retroactive reimbursement.

I am not able to pay full fee for therapy and I have discussed a sliding scale fee with Ray of Hope Child Therapy Services Inc and we have agreed upon a session fee.

I have been informed and agree to hold Ray of Hope Child Therapy Services Inc, harmless from any losses, damages, liabilities, costs and expenses (including and without limitation of attorney’s fees) arising from the release of such information to my insurance carrier, or to a third-party payer or to any other agent as designated by me.

I am aware that the practice of psychotherapy is not an exact science and so predictions of the effect are not precise or guaranteed. I acknowledge that no guarantees have been made to me regarding the results of treatment.

I understand that regular attendance will produce the maximum benefit, but that I am free to discontinue treatment at any time. If I decide to do so, I will provide notification at least two weeks in advance so that effective planning for termination and or continued treatment elsewhere can be implemented. I am aware that I will still be responsible for payment for the services that I received.

Today's Date *

YYYY

By typing my full name, I agree to the above. *

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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