Financial Policies and Authorization

Today's Date*

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.

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*

I authorize LIGHTHOUSE CHRISTIAN COUNSELING to charge my sessions through the method I indicate below.

Recurring Payment Choice*

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 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?*

Phone

This field is for validation purposes and should be left unchanged.

Financial Policies and Authorization

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