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Client's Name
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Fees
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Please check the box to agree.
The fee for the individual intake session of one and one-half hours is $200.00. The fee for a regular counseling session of 45 minutes is $100.00 per session. Longer sessions are available upon request. If your gross family income or special circumstances do not allow you to pay the full fee, please feel free to talk with Dr. Davis about your needs. Emails, texts and phone calls concerning therapeutic matters will be charged in 15-minute increments, with a minimum of 15 minutes.
Please check one or more of the boxes below to indicate which type of session or sessions you are interested in.
Please check all boxes that apply:
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Intake Session (Fee $200.00)
Standard Session (Fee $100.00)
55-Minute Session (Fee $125.00)
75-Minute Session (Fee $175.00)
90-Minute Session (Fee $200.00)
Testing Fee ($150.00 per hour)
Brain Spotting Intensive Session (90 minutes $250.00)
Brain Spotting Intensive Session (2 hours $325.00)
Brain Spotting Intensive Session (3 hours $475.00)
Insurance
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Dr. Davis no longer accepts insurance as a form of payment.
Late Cancellations & Missed Appointments
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Dr. Davis requests a 24-hour notice for appointment cancellations. Clients who cancel within 24 hours of an appointment will be charged one-half their customary fee. Clients who do not show up for an appointment will be charged the full fee for the appointment. Two consecutive "no show" appointments will be considered a termination.
Payment Arrangements
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Payment is due when services are rendered. Accounts are to be kept current unless you have made other arrangments with Dr. Davis.
Returned Checks
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It will be necessary to charge a fee of $30 to the client for each check returned by the client"s bank.
Client Signature
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Date
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