Reduced Fee Form — Couples, individual, and family therapy

Need a reduced fee?

Please provide some information so I can consider your request

IMPORTANT: Before filling out this form, please contact your insurance company to see if they offer any out-of-network benefits. You can find detailed step-by-step instructions for how to do this here.

Other ways to reduce the cost of therapy are to pay using HSA or FSA funds. If you itemize on your annual taxes, therapy is considered a medical expense and can be included in your deductions. Please speak with your tax professional to ensure you are not breaking any rules.

Name

First Name

Last Name

Phone

(###)

###

####

Please let me know your gross total annual income (combined if a couple).

Please let me know if you have children, and if so, how many.

My fees are per hour, $275 for individual therapy, $450 for couples. Please let me know what rate you can afford.

Have you verified through your insurance if they will cover any portion of the fee?

Yes

If your insurance will cover a portion of the fee, what is that amount or percentage? (If they will not cover anything, write "NA.")

Please provide any other relevant information that might help us come to an agreement.