Patient Financial Agreement

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					                                       Client Financial Agreement

Thank you for choosing Legacy Counseling for your counseling needs. I am committed to providing you
with quality therapeutic services. I also want you to have a clear understanding of the costs involved with
your counseling. Please carefully review the following information and return this form with your
signature. If you have any questions about fees, please ask.

Client Information:
You must complete the “Client Information Form” before your first therapy session and update this form if
there are any changes to information provided.

Session Fees:
The initial intake appointment fee is $125. Additional sessions are $100 per clinical hour. A clinical hour
is 50 minutes.

Filing Insurance:
As a courtesy to clients, I will file insurance claims on those insurance panels in which I am an approved
provider. Please keep in mind that whatever your insurance company does not pay, you are responsible for
the remainder of the balance. For those clients with insurance copays, they are due at the time of each
appointment.

Payment for Services:
Your payment will be taken at the beginning of each therapy session. Acceptable forms of payment
include cash, check, and PayPal. You may pay via PayPal by visiting www.legacyserviceswichita.com.

Returned Checks:
The charge for a returned check is $30. This charge will be added to your account in addition to the
insufficient fund amount.

Cancellation fees:
Clients who need to cancel appointments are requested to provide 24 hours notice prior to the scheduled
appointment. If you do not show up for an appointment or do not provide the 24 hour notice, a $50 charge
will be assessed for the first occurrence. For any additional occurrence, a full session fee will be assessed.
You will be responsible for payment of these charges. Exceptions may be granted based upon emergent
situations such as sudden illness.

Phone or Email contact:
If I am contacted by phone or email for any counseling related issues other than rescheduling appointments,
a prorated session will be applied after the first 10 minutes. You will be responsible for paying this fee.

Court related and/or report fees:
If I am ordered to testify or submit a report for the court, a fee will be assessed. For a report to be
submitted to the court, a fee of $100 per hour will be charged to you. You are responsible to make payment
arrangements for the report prior to it being released.

If I am required to testify at court, I will assess fees for preparation time, travel expenses, and actual time
spent at court. Preparation time and travel time will be billed at $50 per hour, and on-site time will be
billed at $100 per hour.

I have read and understand the Client Financial Agreement.



_______________________________________________                             ___________________
Client Signature                                                                   Date




                7340 West 21st St, Ste 101M, Wichita, KS 67205, 316-361-6850

				
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posted:9/16/2012
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