Couples Contract Please enable JavaScript in your browser to complete this form.Client Name *FirstLastClient Name *FirstLastFees *Please check the box to agree.The fee for the intake session for marriage counseling of one and one-half hours is $300.00. The fee for the basic marriage counseling session of 60 minutes is $150.00 per session, and Dr. Davis recommends 90-minute sessions for best outcome. (Longer sessions are available upon request or as needed.) 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: *Intake Session (Fee $300.00)60-Minute Session (Fee $150.00)75-Minute Session (Fee $185.00)90-Minute Session (Fee $225.00)One Day Intensive Session (6 hours $1,250.00)Two Day Intensive Session (12 hours $2,500.00)Intenstive marriage counseling sessions are to be paid in advance when scheduling the appointment.Insurance *Please check the box to agree.Dr. Davis no longer accepts insurance as a form of payment. Late Cancellations & Missed Appointments *Please check the box to agree.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 *Please check the box to agree.Payment is due when services are rendered. Accounts are to be kept current unless you have made other arrangments with Dr. Davis.Returned Checks *Please check the box to agree.It will be necessary to charge a fee of $30 to the client for each check returned by the client's bank.Client Signature *Clear SignatureDate *Submit