![]() Print Name: Print Name:Print Name: Guardian Signature _ Date Relationship to Child: Signature of Witness Date Initial Therapy Session: NOTICE OF PRIVACY PRACTICES and ACKNOWLEDGMENT BY PARENT/GUARDIANTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. Initial Intake Interview and review of records $200.0045-minute Individual Therapy Session $130.00 Assessment, Scoring, and Report writing per hour $130.00 Missed Appointment $130.00Other professional services per hour* $130.00Late Cancellation (less than 24 hrs) $130.00Returned Checks $30.00 *Other professional services include but are not limited to frequent telephone calls lasting longer than 10 minutes, preparation of records or treatment summaries, consulting with other professionals per your request. It makes me still sad – don’t feel comfortable discussing” “I don’t think about many details of things that hap- pened. We ask that you commit yourself to the timely payment of your agreed upon portion of the charge.FEES Initial Assessment$160Session (1 hour)$130Session (45 minutes)$100Group Therapy Session (1 hour)$50/personLate Cancellation Fee/No Show Fee$75TestingVaries depending on tests administeredReturned Check$25*We accept cash, checks, VISA, MASTERCARD, AMERICAN EXPRESS and DISCOVER. ![]() ![]() Examples of Therapy Session in a sentence
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