Healing Wings Professional Counseling ~ 2701 Cleveland Ave NW, Canton, OH 44714 (330) 327-3163
Name(s):
Address: City: State: Zip:
Bill to: Person responsible for payment of account:
Address: City: State: Zip:
Federal Truth in Lending Disclosure Statement for Professional Services
Part One Fees for Professional Services
I (we) agree to pay , hereafter referred to as the clinical unit, a rate of $ per clinical unit (defined as 45–50 minutes for assessment, testing, and individual, family and relationship counseling).
Sessions, if necessary, may be required to be longer if time is available for client and therapist.
A fee of $ is charged for group counseling. The fee for testing includes scoring and report-writing time.
A fee of $ $35.00 is charged for missed appointments or cancellations with less than 24 hours notice.
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Phone Calls: Over 10 minutes duration and/ or after 6pm |
$ 35.00 per ½ hour |
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Court, Doctor, and all professional consultations/visits (Drive time if off day + fee) |
$ 75.00 for 1hr |
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Psychological evaluations for referrals or Medical physicians |
Session fee plus $50 |
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Couple Therapy or additional member brought to a session |
Session fee plus $10 |
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Family Session/Therapy = up to 4 members in a session; additional $10 per |
Session fee plus $20 |
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Case Summaries and Psychological Testing |
$35 to $100 |
Part Two Clients with Insurance ( Agreement)
We suggest you confirm all provisions with your insurance company. The Person Responsible for Payment of Account shall make payment for services to Healing Wings Counseling in full. Patient will be responsible for seeking reimbursement from your insurance company. We do not accept 3rd party payments because of the excessive demands insurance companies place on time and services. We believe this time is better spent on our clients and therefore offer an adjusted rate schedule for those who have some financial hardship with fees.
Adjusted Fee schedule is based on income levels and all clients are treated on a fair and equal basis. Proof of income must be presented to be eligible. (See Adjusted Fee Schedule Form.)
Payments are due at time of service. There is a 15% per month interest charge on all accounts that are not paid within 30 days of the billing date.
I HEREBY CERTIFY that I have read and agree to the conditions and have received a copy of the Federal Truth in Lending Disclosure Statement for Professional Services.
Person responsible for account: Date: / /
Person(s) receiving services: Date: / /
Person(s) or guardian(s):
