Super Clear Terms

If it’s not in writing…

When I first heard of a therapy client demanding a refund because they “didn’t get better”, I almost feel off my chair! Then I ran straight to my documentation to make an important edit!

This is the Fee Schedule and Payment Agreement I use in my practice. It has been developed over the course of many years and encounters, as well as encounters colleagues have had with clients about fees, charges, collections, etc.

While no document can guarantee trouble-free collections, having terms and expectations on a separate document from practice policies ensures more clear informed consent and fewer issues overall.

This document covers:

• Session payment and terms

• Late cancel, no show, and balance terms and fees

• Chargebacks

• Other Fees (e.g. phone consultation, letter writing, records retrieval)

• Authorized charges

• Card types (e.g.HSA/FSA/HRA) and card ownership

This form is dowloaded as a PDF, and was built in SimplePractice’s “Intake Forms” section. This was done to facilitate multiple e-sign acknowledgements throughout the document.

(You will notice my state’s document retrieval fees are included on the form. Be sure to customize this fee to your state’s current maximum.)

NOTE: This form has never been through a chargeback, legal proceeding, or legal review. However, it has been carefully designed and adapted based on feedback from others who have done so. Use of any part of this agreement does not imply any form of guarantee of compliance with any governing body. You are solely responsible to reference your payer contracts, licensing bodies, and professional organizations for specific requirements and adapt your own document to meet these requirements.

Have a shortage of time?
I can add this form to your SP account with any changes you request.