Financial Agreement

  • Family Revelations Inc.

    FINANCIAL AGREEMENT

    The rates for therapy are as follows:

    Payment is due on the day of your scheduled appointment. Family Revelations Inc. can take checks, Visa/MasterCard or cash. Make your checks payable to Family Revelations. Family Revelations Inc. does offer a sliding fee scale for those who are unable to pay the full amount of therapy. This amount must be agreed upon through communication with your therapist.

     

    No-Shows/Missed Appointments/Late Cancellations
    **It is your responsibility to make and keep your appointments**

    Cancellations: 24 HOURS ADVANCED NOTICE IS REQUIRED TO AVOID A CHARGE FOR A MISSED SESSION

    If the client does not show up for an appointment and fails to cancel the appointment, or if the client gives less than 24-hour notice of a cancellation there will be a fee charged to the client’s account. The late cancel fee and missed appointment fee will be $45.00

    Intake Individual Counseling Couples/Family Therapy
    $225.00 (Per session) $85.00 (Per 45 min session) $140.00 (Per session)
    Sliding scale / Private Pay amount (TBD)$:Click or tap here to enter text. $ Sliding scale / Private Pay amount (TBD)$ Click or tap here to enter text.: $ Sliding scale / Private Pay amount (TBD)$: $

    I have read and understand the Financial Policy in its entirety and agree to the following:

    • I understand that I am responsible to pay my co-pay or sliding scale fee or expences not covered by insurance.
    • I understand that co-pays/session fees are due at the time of service
    • I understand that if I am unable to maintain the terms of this agreement I will immediately notify Family Revelations Inc.

    This agreement is valid for one full year upon the date of your signature.

  • Date Format: MM slash DD slash YYYY
  • Family Revelations Inc. 1705 Cope Ave East Suite I Maplewood, MN. 55109

    Family Revelations Inc. 1303 So. Frontage Road, Suite 275 Hastings, MN. 55033