ABC’d Therapy & Consulting, LLC
6842 University Avenue, Ste B
Windsor Heights, IA 50324

Financial Agreement


  1. Payment is due at the time which services are rendered, unless prior payment arrangements have been made.
     
  2. Charges for counseling services are: $200 for an initial assessment, and $175 per clinical hour for Individual and Couples Counseling (approximately 50 minutes). Virtual sessions are scheduled at the discretion of the therapist and may be covered by some insurance plans. If you are paying out of pocket for your session, a discount of $45 will be applied to your account per session ($130). A $35.00 fee will be charged for returned checks due to insufficient funds. Group therapy rates will vary according to the group. Please inquire with the therapist. All credit card charges will incur a $1.50 additional service fee.
     
  3. Cancellation Policy: A 24-hour notice is required for cancellation of all scheduled counseling appointments. If a client fails to cancel a scheduled appointment and does not arrive for his/her scheduled appointment time, this time cannot be used for another client. Therefore, clients will be charged for 1 (one) clinical hour at the standard rate of $130.00 for all “no show” counseling session appointments. If a client cancels within 24 hours before the scheduled session, a fee of $65 will be charged. These fees will be charged to your credit card on file. Insurance does not typically cover these fees.
     
  4. I understand that in the event of non-payment of fees, my counselor will seek resolution using my name, address and phone number to collect outstanding fees. This may precipitate legal recourse.
     
  5. Research, reports and letter writing are $130.00 per hour.
     
  6. If you choose to use insurance for payment of your therapy session, it is your responsibility to verify your eligibility and its use at ABC’d Therapy & Consulting, LLC. We will agree to submit claims for you, but you remain solely responsible for all fees incurred for services and their payment. This includes co-payment at the time of service, and any denied claims or late fees.

    Please select your preferred payment method below:

    Yes, I would like to use my insurance benefits for mental health services. I understand the limits to my confidentiality and my responsibility for payment of services if my insurance company denies my claim.

    No, I would like to pay out of pocket for my mental health services.

  7. We require that a credit/debit card be kept on file with the office. This information will be secured in your file and will only be used for (1) payment for a missed scheduled appointment for which a 24 hour notice of cancellation was NOT provided, (2) any unpaid balance over 60 days for which payment arrangements have not been made, (3) payment for sessions at the request of the client.
     
    Name as it appears on the credit card:  
    Visa         MasterCard         Discover         AMX

    Credit Card Number:  

    Expiration Date:  
    CVV code (on back of card):  
    Zip Code for card billing address:  

By signing my name below, I acknowledge that I have read and understand this agreement in full and agree to its conditions. I agree to make payment to ABC’d Therapy & Consulting, LLC at the time of services, unless payment arrangements have been made. I agree to give notice of twenty-four hours or more if I am unable to attend a scheduled appointment.

If I do not give twenty-four hours notice, I understand that I am responsible for payment, in full, of the standard fee which is $130.00. I agree to these terms and authorize my credit card to be charged for any cancellation fees I may incur, or for any unpaid billing statements more than 60 days in arrears. If I fail to pay any amount due, I will be responsible for all collection fees, court costs and attorney fees.

Signature: (Type your name in the field below to create a binding signature)

Date: