Agreement for Payment and Financial Responsibilities Sample Contracts

Therapist: AGREEMENT FOR PAYMENT AND FINANCIAL RESPONSIBILITIES
Agreement for Payment and Financial Responsibilities • January 14th, 2022

Care and Counseling is a non-profit counseling center, accredited by The Solihten Institute. The standard fee for a first evaluation appointment is $190 and the standard fee for ongoing counseling is $175 per 38-67 minute session. We also have a Client Assistance Fund for those whose income cannot support the standard fee. Annually we review fees and renew the agreement for payment. There is a cost of living increase typically 1-2% each year. Please complete the following and return to your counselor.

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AGREEMENT FOR PAYMENT AND FINANCIAL RESPONSIBILITIES
Agreement for Payment and Financial Responsibilities • July 12th, 2021

Care and Counseling is a non-profit counseling center, accredited by The Solihten Institute. The standard fee for a first evaluation appointment is $190 and the standard fee for ongoing counseling is $175 per 38-67 minute session. We also have a Client Assistance Fund for those whose income cannot support the standard fee. Annually we review fees and renew the agreement for payment. There is a cost of living increase typically 1-2% each year. Please complete the following and return to your counselor.

Therapist: AGREEMENT FOR PAYMENT AND FINANCIAL RESPONSIBILITIES
Agreement for Payment and Financial Responsibilities • November 20th, 2019

Care and Counseling is a non-profit counseling center, accredited by The Solihten Institute. The standard fee for a first evaluation appointment is $190 and the standard fee for ongoing counseling is $175 per 38-67 minute session. We also have a Client Assistance Fund for those whose income cannot support the standard fee. Annually we review fees and renew the agreement for payment. There is a cost of living increase typically 1-2% each year. Please complete the following and return to your counselor.

AGREEMENT FOR PAYMENT AND FINANCIAL RESPONSIBILITIES
Agreement for Payment and Financial Responsibilities • August 14th, 2020

Gloria Dove works with a mission to improve emotional, and relational well-being through quality and affordable counseling, professional training, and community education. The standard fee for a first evaluation appointment is $175 and the standard fee for ongoing counseling is $125 per 60-minute session. We also have sliding scale for those whose income cannot support the standard fee. Annually we review fees and renew the agreement for payment. There is a cost of living increase typically 1-2% each year. Please complete the following and return to your counselor.

Therapist: AGREEMENT FOR PAYMENT AND FINANCIAL RESPONSIBILITIES
Agreement for Payment and Financial Responsibilities • April 7th, 2020

Care and Counseling is a non-profit counseling center, accredited by The Solihten Institute. The standard fee for a first evaluation appointment is $190 and the standard fee for ongoing counseling is $175 per 38-67 minute session. We also have a Client Assistance Fund for those whose income cannot support the standard fee. Annually we review fees and renew the agreement for payment. There is a cost of living increase typically 1-2% each year. Please complete the following and return to your counselor.

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