Our current fee is $140 per
session. The initial session is $150 for adults, $155 for
children, adolescents, and/or families. Court-related cases are $180
per session. The “intake process” is three sessions and is used to
determine the clinical needs of each individual and the “fit” with the
therapist. The duration of a session is 50 minutes, which is known as
the “clinical hour.” Payment is expected at the end of each
therapy session unless prior arrangements have been made. Any
changes in this agreement must be approved by your therapist.
CHARGES: There will be a
charge for phone calls or preparation of insurance claims if they exceed
15 minutes and will be billed at the half-hour rate of $70.
Occasionally, scheduled session time will be devoted to filling out
insurance forms in order to minimize costs, and to keep you fully
informed of what is disclosed to your insurance company, this cost is
not covered by insurance companies.
When psychological tests are administered, or if reports of any kind are
prepared for another party or you, there will be an additional charge.
If you are not sure if this applies to you, please ask your therapist.
Phone sessions will be billed at the standard therapy session rate in
half-hour increments when they exceed 15 minutes. There will be a $33
charge for returned checks. A finance charge of 2% per month will be
calculated on all balances over 90 days due.
MISSED & CANCELLED APPOINTMENTS:
Since scheduling of an appointment
involves the reservation of time specifically for you, missed
appointments and cancellations less than 24 hours prior to the
scheduled appointment will result in a charge for that time. Our phone
is answered 24 hours per day and a message is sufficient notice during
times when the office is closed.
FAILURE TO PAY YOUR BILL:
Financial hardships may occur to any of
us. These hardships should be discussed with your therapist as soon as
they develop, so that necessary changes in your payment agreement may
possibly be made. Non-payment may result in collection efforts or legal
action. If an account is sent to collection, you will also be held
financially responsible for all collection fees assessed to our
Some insurance carriers select a panel of providers to deliver therapy
services and my not reimburse for services from other professionals
outside their network. It is recommended you contact your insurance
representative for pre-approval to confirm your coverage. We are a
fee-for-service practice, thus, insurance reimbursements should be sent
directly to you.
Information revealed in your session is
confidential and will not be released to others without your
permission. Several legally required exceptions to
confidentiality include situations of potential harm to oneself
or others, incidents of child abuse (Ohio has a mandatory child abuse
reporting law), incidents of elderly or dependent abuse and situations
where a court may order records.
As a client of Palmentera & Associates, Inc. I understand that I am
financially responsible for professional services by me or those for
I am responsible. It is my intention to carry out my financial
to Palmentera & Associates, Inc. in the following
___________ I will pay for all professional services at the time they
are offered. I will file my own insurance claims and request that
Palmentera & Associates, Inc. provide me with statements and/or
receipts. (Note: All court-related services fall into this category.)
___________ Other (please specify)/ Comments:
I understand Palmentera & Associates, Inc. service, fee and payment
policies and agree to comply with these conditions. I understand all
charges for services rendered are my responsibility.
Name of Client:____________________________________________
Date of Birth:______________________________________________
Signature of Client/Responsible Party:
Signature of Therapist: