Scribd Logo
Upload

Welcome to Scribd!

  • Gayle G Anderson, M.A., PLPC: Supervisor: V. David Weiss, M.S., LPC

    Uploaded by

    api-55970082
    19 views1 page
    This document is an agreement for a client to pay for professional therapy services. It states that the client agrees to pay the therapist's fee of $__ per session. It also specifies that the client is financially responsible for sessions until ending the relationship either in person or via certified mail. The client must also meet with the therapist at least once before stopping therapy and is responsible for all charges until ending the relationship, even if insured or other parties make payments. The client confirms reading and agreeing to the therapist's information brochure by signing the document. The therapist also signs, attesting that the client is competent to provide consent.

    Original Description:

    Original Title

    Untitled

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document is an agreement for a client to pay for professional therapy services. It states that the client agrees to pay the therapist's fee of $__ per session. It also specifies that the client is financially responsible for sessions until ending the relationship either in person or via certified mail. The client must also meet with the therapist at least once before stopping therapy and is responsible for all charges until ending the relationship, even if insured or other parties make payments. The client confirms reading and agreeing to the therapist's information brochure by signing the document. The therapist also signs, attesting that the client is competent to provide consent.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    19 views1 page

    Gayle G Anderson, M.A., PLPC: Supervisor: V. David Weiss, M.S., LPC

    Uploaded by

    api-55970082
    This document is an agreement for a client to pay for professional therapy services. It states that the client agrees to pay the therapist's fee of $__ per session. It also specifies that the client is financially responsible for sessions until ending the relationship either in person or via certified mail. The client must also meet with the therapist at least once before stopping therapy and is responsible for all charges until ending the relationship, even if insured or other parties make payments. The client confirms reading and agreeing to the therapist's information brochure by signing the document. The therapist also signs, attesting that the client is competent to provide consent.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    Gayle G Anderson, M.A.

    , PLPC
    Supervisor: V. David Weiss, M.S., LPC

    Agreement to Pay for Professional Services


    I request that the therapist named below provide professional services to me or to ______________________________,
    who is my ___________________________________ , and I agree to pay this therapist’s fee of $ _____ per session for
    these services.

    I agree that this financial relationship with this therapist will continue as long as the therapist provides services or until I
    inform him or her, in person or by certified mail, that I wish to end it. I agree to meet with this therapist at least once
    before stopping therapy. I agree to pay for services provided to me (or this client) up until the time I end the relation-ship.

    I agree that I am responsible for the charges for services provided by this therapist to me (or this client), although other
    persons or insurance companies may make payments on my (or this client’s) account.

    I have also read this therapist’s “Information for Clients” brochure and agree to act according to everything stated there,
    as shown by my signature below and on the brochure.

    ____________________________________________ ____________________________________________
    Signature of client (or person acting for client) Date

    ____________________________________________
    Printed name

    I, the therapist, have discussed the issues above with the client (and/or the person acting for the client). My
    obser­vations of the person’s behavior and responses give me no reason to believe that this person is not fully
    competent to give informed and willing consent.

    ___ _________________________________________
    Signature of therapist Date

    You might also like