Form #25

PAYMENT AND CREDIT POLICY

Clients are ultimately responsible for their own payment of services, regardless of insurance
benefits.  Insurance claims can be submitted more easily and quickly for you by Arrowhead Family
Counseling if you complete the assignment of benefits agreement below, which allows us to file
your claims and accept payments directly from insurance.  We may use  electronic methods of
communication unless you indicate otherwise.You will be billed for any balance remaining after the
insurance payment is received.  Legal expenses or other costs incurred in collecting delinquent
accounts will be your responsibility.  Please note our 24 hour scheduled appointment.  There
is a limit of three such cancellations followed by termination.  You are encouraged to
discuss any payment concerns without delay to avoid any misunderstandings regarding this policy.

Client Signature ______________________________________________

Date ________________________

ASSIGNMENT OF BENEFITS

I understand the above policy and I hereby authorize Arrowhead Family Counseling to obtain all
benefit information on my behalf and to release any health related information, electronic or
otherwise, which might be needed in connection with payment for professional services rendered.

Client Signature ______________________________________________

Date ________________________

FEE SCHEDULE

INTAKE/DIAGNOSTIC INTERVIEW             $120.00
INDIVIDUAL THERAPY                                  $120.00
INDIVIDUAL THERAPY                                  $60.00
FAMILY THERAPY                                          $120.00
GROUP THERAPY                                           $60.00/person
CONSULTATION                                            $120.00/negotiable
LATE (less than 24 hours) CANCEL                  $20.00