Sample: Financial Policy

This counselor is committed to providing the best counseling available. It is important to understand that credit and collections policies are a necessary part of assuring the continuity of this care for you, other clients, and our community. In order to provide these services a fee is charged for each session. The amount of that fee is adjusted in accordance with the client’s ability to pay, based on his/her family’s gross income.

It is the financial policy of this counselor to collect payment at the time service is rendered. Cash and checks are accepted.

If a check is returned for non-sufficient funds, the bank charge will be assessed to the client’s account. This fee along with the amount that caused the NSF must be paid prior to or at the time of the next appointment.

If circumstances make it impossible to meet these terms, please discuss the matter with this counselor.

Acknowledgement:

I have read and understand these financial policies. I understand that the full fee will be charged for missed appointments without 24-hour advance notice. Furthermore, I understand that charges incurred for missed appointments are not billable to a third party. Therefore, the client is responsible for the full fee.

The agreed upon fee will be $                                       per 50-minute session.

Client and/or Guarantor Signature                                          Date

Printed Name:

Date of Birth and SSN

  Counselor Signature