Fee Agreement Form

ICC Inc. Media Services Portal: Forms

This form is part of the Client Intake Packet. It was last updated May 17, 2021.

Innovative Counseling & Consulting, Inc.

Fee Agreement

This agreement is between you, the client, and Innovative Counseling & Consulting, Inc., to pay a set dollar amount for services. This agreement may be terminated at any time, by either the client or Innovative Counseling & Consulting, Inc.

Part I: The Terms

Instructions: Please enter your initials in the field following each statement to acknowledge and agree to the terms.

1. I will pay $175.00 for Assessment sessions; and $150.00 for all other therapy sessions provided by Innovative Counseling & Consulting.

2. All dollar amounts are subject to change as rates within the agency change. Prior notice of 30 days will be given to the client unless otherwise specified.

3. I will pay my fee on the date that I received service.

4. I am responsible for making all appointments. If I am unavailable for a scheduled appointment, I will contact my therapist 24 hours prior to the scheduled time of appointment. If I do not contact the therapist 24 hours prior to my scheduled appointment, than I agree to pay the session cost (as stated in section 1) for the missed appointment.

5. I understand that l am responsible for the full fee per services received by Innovative Counseling & Consulting, Inc., unless otherwise specified.

6. If my account is not paid in full either by myself or alternative funding for any reason, I understand that my account may be subject to collection under the Laws of Iowa. In any proceedings to collect fees owed by me under this agreement, I authorize Innovative Counseling & Consulting, Inc. to disclose any and all information necessary to make collection, and I waive any therapist-consumer privilege relating to this information.

7. Payments are due at the time of service.

8. Other arrangements may be made for payment, but I understand that if payments are not made by other sources, I am responsible for all payments.

9. I understand there is and agree to pay a 30.00 processing fee for all returned checks.

NOTE: Innovative Counseling & Consulting, Inc. must have a copy of the insurance card, front and back.

Part II: Signature

By clicking “Submit,” you give us permission to email you.

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