(703) 530-9800
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Financial Policy
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Financial Policy
Financial Policy
I understand that I am directly and fully responsible to Calvary Counseling Center for all services rendered to me and/or members of my family by Calvary Counseling Center. I further understand that such payment is expected when services are rendered and is not contingent on any settlement, judgment or insurance payment by which I may eventually recover said fee. Calvary Counseling Center will provide me with receipts, which I can file with my insurance company for reimbursement consideration. I understand that all services rendered by Calvary Counseling Center are final and non-refundable. I understand that all diagnoses and opinions in reports and/or evaluation assessments are offered with a reasonable degree of psychological certainty. I understand that all outstanding balances must be paid in full or satisfied prior to completion of recommended services/treatment plan. I understand that drug screenings, psycho-educational groups (DUI,HOPE), brief solution focus sessions, individual and discharge sessions are invoiced through SQUARE (www.squareup.com). I understand that all fees are non-refundable and/or transferable. I understand that no show fees and cancellation fees are $100. I have read the above and understand my responsibilities in each instance regarding payment of services rendered.
Patient/Responsible Party’s Digital Signature
Home Phone
Cell Phone
Email
Date Signed
NOTE: It is our policy to charge for telephone consultations lasting more than 5 minutes. The charge will be pro-rated on base rate of $125/hour. Cancelled phone or office appointments with less than 24 hours notice and all no-shows will be charged $100.
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