Community Sponsorship Agreement

It is our mission at Lighthouse Christian Counseling to provide the opportunity for affordable mental health care. It has been our passion to come alongside individuals, couples, and families to provide counseling and prayer through the love and hope that only God can provide. Due to Medicaid's terms & policies, we are not able to bill a Medicaid card policy holder. We adhere to Medicaid's rules and regulations; their policy states that if there are mental health services rendered in the area that accepts Medicaid, the client must see that provider who is in Network. Please refer to the Colorado's Department of Health Care Policy and Financing website and "Policy Statement: Billing Health First Colorado Members for Services” for further information.

Client Name*
First Last
Community Sponsor Name*
First Last
Community Sponsor Phone Number*
Lighthouse Christian Counseling Community Sponsorship Agreement*
I understand and agree that I am 100% financially responsible for the fees incurred through the clients services at Lighthouse Christian Counseling.
It is our mission at Lighthouse Christian Counseling to provide the opportunity for affordable mental health care. It has been our passion to come alongside individuals, couples, and families to provide counseling and prayer through the love and hope that only God can provide. Due to Medicaid's terms & policies, we are not able to bill a Medicaid card policy holder. We adhere to Medicaid's rules and regulations; their policy states that if there are mental health services rendered in the area that accepts Medicaid, the client must see that provider who is in Network.

Please refer to the Colorado's Department of Health Care Policy and Financing website and "Policy Statement: Billing Health First Colorado Members for Services” for further information.

This agreement below indicates that a sponsor will be 100% financially responsible for the fees incurred through the clients services at Lighthouse Christian Counseling.
Lighthouse Christian Counseling Community Sponsorship Agreement*
I agree to the payment and cancellation policy.
PAYMENTS/CANCELLATIONS:
The fee for therapy is based on a sliding fee scale based on information provided below and is the fee for a 50 minute session. The fee will be discussed with you prior to your first appointment.

Payment of your fee is expected at the beginning of each session. A pro-rated fee will be charged for phone consultations greater than 5 minutes in duration, talking with professionals at your request, and any written correspondences.

If a court appearance/deposition is required, please ask for the separate consent form.

The full session fee is charged for appointments at which you do not show or cancel with less than 24-hour notice of the reserved appointment time. Two-hour sessions must be cancelled one week in advance. A $20 fee will be charged for all checks (payments) returned for insufficient funds.
Please refer to the Colorado's Department of Health Care Policy and Financing website and "Policy Statement: Billing Health First Colorado Members for Services” for further information.

This agreement below indicates that a sponsor will be 100% financially responsible for the fees incurred through the clients services at Lighthouse Christian Counseling.
This agreement is in effect until:*
You can define this in a number of ways: 1) # of sessions 2) Amount of money 3) Period of time 4) A certain event occurs 5) NA: The agreement will continue indefinitely
Today's Date*
MM slash DD slash YYYY
Consent*
I authorize LIGHTHOUSE CHRISTIAN COUNSELING to charge my Credit Card for the above client's sessions.
Type of Card*
- Visa
- MasterCard
- Discover
Name on Card*
Card Number*
Expiration Date*
3 Digit Security Code*
Address Associated with the Card*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Would you like to receive our email newsletter we send 1-2 times a month?*
Email*
Thank you for caring and supporting this person.
If we need anything else, Ann will reach out to you. Otherwise, you are done!

Community Sponsorship Agreement

Community Sponsorship Agreement

Thank you for caring and supporting this person.

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5236 Strauss Cabin Rd, Fort Collins, CO 80528
info@lighthousecounselingnoco.com