Forms and Fees

FORMS

 

Please print and fill out the Counseling Application Form and Consent to Treatment Form, and bring these to your first session with me. Please print and fill out the Consent to Release Information Form if you would like to release any information to someone (ie. doctors, psychiatrist, family members, etc).

THERAPY COST

 

I charge $140 per 50 minute session. Payment is due at the time of service. I accept cash or check at this time. Please write checks out to "Cluff Counseling".

 

 

FEE AGREEMENT

 

The billable therapy hour is 50 minutes, in order to allow pre-session planning and post-session documentation.  If the session extends past the hour,

I will endeavor to solicit permission to extend the session and inform you of the rate adjustment for the session.

 

 If you are unable to keep an appointment, you must notify me at least 24 hours prior to your appointment time. To cancel an appointment, call me at 817-773-7715. If I am unable to answer your call, please leave a voicemail message and your call will be returned within 24 hours.

 

You are responsible for keeping your scheduled appointments. With the exception of an emergency, you will be billed for all missed appointments that are not canceled at least 24 hours ahead of time.

 

In instances where a third-party, such as an ecclesiastical leader, has taken responsibility for payment, you must present a letter, signed by the third-party, stating their willingness to pay for services.

 

Although I am not on any insurance panels, I will be happy to provide a monthly superbill for you to submit to your insurance company, at your request.

 

I do not provide witness or expert testimonies for court hearings.

  860 Hebron Parkway, Suite 1102, Lewisville, TX 75057 |        2017 | Cluff Counseling | All rights reserved.