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Our Staff
Chris Bassett, LMFT
Kathy Estep, LPCC
Maggie Kelleher, LPCC
Ramona McGonagil, LPCC
Micah Strouse
Bob Weinkauf, MA
Jen Hahn, LPC
Emily Baker
Jacqueline Elliff, LPC
Our Services
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Relationship Counseling
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About Us
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Financial Policies and Authorization
Submit a document
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3rd Party Recurring Payment Authorization
Consent for Release of Information
Collateral Contact Form
blog
Contact Us
Home
Our Staff
Chris Bassett, LMFT
Kathy Estep, LPCC
Maggie Kelleher, LPCC
Ramona McGonagil, LPCC
Micah Strouse
Bob Weinkauf, MA
Jen Hahn, LPC
Emily Baker
Jacqueline Elliff, LPC
Our Services
Individual Counseling
Relationship Counseling
Child & Family Counseling
Reunification Therapy
About Us
Session Fees
COVID Considerations
Forms
Intake Packet
Financial Policies and Authorization
Submit a document
Community Sponsorship Agreement
3rd Party Recurring Payment Authorization
Consent for Release of Information
Collateral Contact Form
blog
Contact Us
Financial Policies and Authorization
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Financial Policies and Authorization
Financial Policies and Authorization
Recurring Payment Authorization and Consent to Financial Policies
Today's Date
*
MM slash DD slash YYYY
Client Name
*
First
Last
Phone Number
*
Consent
*
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.
Lighthouse does not release case notes, even to the client. When requested, and with a Signed Release of Information form, the counselor will write a summary. This is billed by the minute at the client's session rate.
**REUNIFICATION BILLING IS DONE SEPARATELY AND IN A DIFFERENT MANNER, WITH A DIFFERENT COST**
If you want to use the sliding fee scale, indicate your annual gross (pre-tax) income for your household.
Less than $35,000
$35,000 - $55,999
$56,000 - $70,999
$71,000 - $90,999
$91,000 - $105,999
$106,000 - $119,999
Above $120,000
If you do not answer this, you will automatically be charged for the standard fee for your counselor (Reunification pricing agreement is in a separate form).
Returned Funds Policy
*
I understand LIGHTHOUSE CHRISTIAN COUNSELING will add a $20 charge for non-sufficient funds.
Recurring Payment Authorization
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I authorize LIGHTHOUSE CHRISTIAN COUNSELING to charge my sessions through the method I indicate below.
Recurring Payment Choice
*
Credit/Debit/Other Card
Other Party is Paying
If choosing cash or check, we will still need a card on file in case of late cancellations, no-shows, or lack of payment. Thank you.
Type of Card
*
Visa
MasterCard
Discover
Name on Card
*
Card Number
*
Expiration Date
*
CVV
*
Address Associated With This Card
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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Cook Islands
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Guyana
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Hungary
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Indonesia
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Iraq
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Italy
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Japan
Jersey
Jordan
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Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
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Liberia
Libya
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Maldives
Mali
Malta
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Mexico
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Montserrat
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Myanmar
Namibia
Nauru
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Netherlands
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Nigeria
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Oman
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Palau
Palestine, State of
Panama
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Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
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Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
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Samoa
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Sierra Leone
Singapore
Sint Maarten
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Slovenia
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Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
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Sudan
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Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Who should we contact about payment?
*
What is the phone number of the person who will be paying for your sessions?
*
What is the email of the person who will be paying for your sessions?
*
Consent
*
I agree to the financial policies and to the payment forms I have entered.
Aknowledgement of Good Faith Estimate for Health Care Services
*
Per the No Surprises Act you are entitled to receive a good faith estimate for your services here at Lighthouse. You can contact our office to request your estimate at any point in time before or during your treatment at Lighthouse.
Would you like to receive our email newsletter we send 1-2 times a month?
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Phone
This field is for validation purposes and should be left unchanged.
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