Establishment of Fee Form - Brown-Gratchev &Associates Counseling

[ ] New Date: ____________________
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ESTABLISHMENT OF FEE FORM

Client Name(s):_________________________________________________
_ Yearly/Monthly Gross Income: ___________ # of Dependents: __________

Sliding Scale Fee: $__________ per individual, couple, group, or family session (if applicable, due to financial hardship or lack of eligible insurance coverage).

-OR-

Full Professional Rate Fee: $100.00 per hour for individual, couple, or family sessions or $65.00 per group therapy session.

(NOTE: if you request that your insurance be used for payment of services, then:
- your insurance firm will be contacted by phone or in writing to obtain pre-certification of benefits (whether they will provide coverage to our firm, the terms of coverage, and how to file a claim
- you will be notified of the results of the pre-certification of benefits (specifically what your deductible and/or co-pay portion per session will be, if coverage will be provided)
- claims will be submitted on a monthly basis to your insurance firm to obtain reimbursement for our firm, and this usually will require your signature (NOTE: insurance firms require limited disclosure of confidential information including a diagnosis)
- pre-certification of benefits by an insurance company occasionally can run into a snag; that is, pre-certification may be provisionally granted, then, on full review of a submitted claim, the insurance company may deny the claim for a variety of reasons (if this occurs, you will be immediately notified of this by our firm and you will be retro-actively billed by us only for what would be the [lower] sliding scale fee rate for you, and no more than that rate, OR, if affordable to you and at your agreement, you will be billed at the Full Professional Rate Fee of $100.00 per hour, OR at a lessor maximum rate set by the specific insurance company instead of the sliding scale fee rate. If services are provided beyond the coverage limits of insurance, then you will be charged either the full amount, if you can afford it, or the appropriately set sliding scale fee rate.)

Our primary interest is to provide you with quality service and to assist you in making informed decisions. For this reason, we want to clarify the following:

CREDIT POLICY

- Your fee is due and payable at the beginning of the time of your session.
- You will be charged your full established fee for all no-shows and late cancellations. Fees for no-shows and late cancellations must be paid before another appointment can be made.

- Delinquent accounts will be assigned to a collections agency and a $20.00 service charge will be added to your account.
- If the bank returns any of your checks, you will be charged a $20.00 fee and you will be placed on a cash only basis.

I HAVE READ THIS CREDIT POLICY AND UNDERSTAND THAT I AM RESPONSIBLE FOR THE PAYMENT OF MY ACCOUNT. I AGREE THAT IN THE EVENT COSTS AND/OR FEES ARE INCURRED IN CONNECTION WITH THE COLLECTION OF MY ACCOUNT, I WILL PAY ALL SUCH COSTS AND FEES. [ top]

CONSENT TO TREATMENT

I understand that treatment may carry with it some risks, such as:
1. Desired outcome may not always be achieved;
2. Symptoms may increase during the course of treatment;
3. Relationships may end;
4. Other: _______________________________________________________
and that recommended alternatives to treatment with Brown-Gratchev & Associates are:
1. Another practitioner, therapist, or organization;
2. Not seeking treatment;
3. Other: _______________________________________________________

- I also understand that I will participate in the development of the final treatment plan, which usually takes place after or during 1 to 3 initial intake sessions, and that I will have the opportunity to review it with Brown & Associates, including frequency of sessions and type of treatment(s).
- Brown-Gratchev & Associates has explained their professional credentials and qualifications to me.
- I have been given the client Welcome Letter which explains general policies and procedures, and a copy of this Consent To Treatment document.
- I understand that if I am using insurance for payment of services, then diagnostic and other information must be furnished to the insurance company by Brown-Gratchev & Associates.
- I understand that I am fee to withdraw my consent to treatment at any time, in writing.
I give Brown-Gratchev & Associates permission to treat myself and/or children listed below:
Children: ______________________________________________________

I HAVE RECEIVED A COPY OF THE WELCOME LETTER AND A COPY OF THIS CONSENT TO TREATMENT DOCUMENT:

Client Signature(s): _____________________________________________

Date: _______________ Ken Brown-Gratchev: _______________________________