Fee Agreement

Payment for services received at Kardia® Counseling & Consulting, PLLC is due when they are provided. As a courtesy to our clients and families, we may bill your insurance company in accordance with information you provide to us. It is your responsibility to keep Kardia® Counseling & Consulting, PLLC informed of any changes to your insurance coverage. All deductibles, co-pays, or fees NOT paid by your insurance carrier that may be required under your insurance plan are your responsibility at the time of service or when billed to you .

Charges are based on the type of service provided to you. If additional time or services (such as telephone sessions or email communications) are provided, a pro-rated fee may be charged. You remain legally responsible for all charges.

Below are a list of common services and fees that clients may encounter. Your provider will discuss these fees with you at the time of the request.

Common Services & Fees

Letters/reports for your insurance company or another agency	$225.00 per hour/request
Court related costs - letters, testifying, forensic reports, etc. (Costs for testifying do NOT include travel time from “door to door” which will be based on standard government rates at that time)	$225.00 per hour/request
Services that are not covered by your insurance company (Certain types of testing, phone sessions, etc.)	$150.00 per hour /request

Missed appointments are also your complete financial responsibility. With sufficient notice, an appointment can generally be re-scheduled. Failure to give 24-hour notice of cancellation will result in a “no-show” charge. “No-Show / Late Cancellation” charges are based on the type of services scheduled listed below.

Intake Session	$225.00 per hour
Individual/Marriage/Couples Therapy Session	$140.00 per hour
Group Therapy Session	$50.00 per hour
RETURNED CHECK FEES	$25.00 per issue

This financial relationship will continue as long as we provide services or until such time as you notify us that you wish to terminate treatment. Once treatment terminates, any balance not paid in full will be considered due. When an account becomes 60 days past due, professional collection may be utilized and/or legal action taken.

My signature below indicates that I have read and understand this fee policy. I agree to leave a credit card on file and to authorize charges for no show fees to be charged to my account.

BY SIGNING I ACKNOWLEDGE THAT I UNDERSTAND THE ABOVE STATEMENTS AND AGREE TO THESE CONDITIONS FOR TREATMENT.

Patient Signature:

Patient Signature Date:

Parent/Legally Responsible Person:

(if patient is below 18 years of age)

Parent Signature Date: