FINANCES
The fee for individual therapy is $85.00. Please be prepared to pay for each session at the time of service unless you have made prior arrangements. If, for any reason, you are unable to attend a scheduled appointment, you will be expected to give adequate notice. There will be a charge for late cancellations, and no-shows. If you are paying through an insurance carrier, you will be expected to pay the difference between what your insurance covers and the fee for service. For example, if your insurance pays 50% you will be expected to pay $40.00 at each session. It will also be your responsibility to:
a. Find out if your insurance covers psychotherapy from a Licensed Clinical Social Worker. If I am not on your insurance panel, your insurance may only pay a portion of the bill, or no portion at all.
b. Obtain an insurance form, if required ( fill out and sign your portion).
c. Determine if you have a deductible and if so how much. If there is a deductible, you will be expected to pay for each session until your deductible is paid.
d. If someone else is paying for your sessions it will be necessary to fill out and sign a release form indicating name, address, and amount that person has committed to pay.
Your signature below indicates you understand and accept the above financial and scheduling
policies. Please note that therapy will require your attention, dedication, and hard work. Even so, there are no guarantees that all your goals will be realized. Each counseling session is set up on a 50 minute basis.
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Client signature (individual)
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Client signature (spouse/guardian)
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James B. Lewis, LCSW, CSAT
Rev: 10/05
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