• Financial Agreement - Self Pay Bundle

    This form is an agreement between you, (parent of a minor or adult client) and Behavioral Health Clinic (BHC). When we use the word "patient” below, it can mean you, your child, or another person for whom you serve as legal guardian.

  • Cancellation of scheduled appointments is required at least 24 hours in advance.

    Failure to cancel within this time frame prohibits this office from scheduling other patients in that time slot. Therefore, if a minimum of 24-hour notice is not received, one session will be deducted from your account for a missed appointment or late cancellation. Please be advised a courtesy waiver of the fee is offered for the first instance of a missed appointment or late cancellation. Chronic missed/late cancelled appointments shall result in being placed on ‘day-of’ appointment scheduling.

  • Severe Weather Cancellations:

    In the event of a severe weather event, there will be no charge for late cancellations of appointments.Please notify our office immediately if you plan to miss a same-day appointment due to a severe weather event so that your clinician may be notified.

  • Refund Policy

    All sales are final and we will not be issuing refunds for any unused services.

  • Transfer Policy

    Patient and therapist match is important to us. If you do not feel your therapist is a good match for you, we will allow you to transfer your remaining sessions to a different provider at Behavioral Health Clinic. This policy requires payment to be paid in full before the appointment. The packages are priced by session and a session fee covers up to 60 minutes of therapy.

    This policy requires payment to be paid in full before the appointment. The packages are priced by session and a session fee covers
    up to 60 minutes of therapy.

    If at any time, you have used all of your sessions from your package, you must purchase another bundle or agree to pay session-to-session at full fee rate.

  • Bundling Packages:

    1) Therapy

    • Intake bundle: First and second session for $350
    • 2 session follow-up bundle: $350
    • 4 session follow-up bundle: $675
    • 6 session follow-up bundle: $1000
    • 8 session follow-up bundle: $1300

    2) Testing

    • Standard* Child ADHD: all-inclusive: $2,300
    • Standard* Adult ADHD: all-inclusive: $1,675
    • Standard* Child Autism: all inclusive: $3,450
    • Standard* Adult Autism: all inclusive: $2,550

     

    *Note: Standard testing quotes are based on standard batteries (see information sheet) that are used to diagnose or rule
    out ADHD and Autism. However, during the clinical interview portion of assessment, you and your clinician may identify
    additional testing that is required to rule out or explore a condition that is not adequately assessed in the standard battery.
    Your clinician will discuss with you the additional measures they recommend to answer the diagnostic question, and our
    office will contact you with a quote on any additional fees that may be suggested as an addendum to this financial
    agreement.

     

  • Payment Information:

    Payment for services provided by BHC is the responsibility of the person receiving those services or, in the case
    of a minor, the parent/guardian signing this financial agreement. Payments need to be made before an appointment can be
    scheduled. You do have the option to keep a credit card on file – as a convenience, BHC can charge your card, when additional bundle
    packages are requested.


    I, the undersigned, acknowledge that I have both read and agree to all the terms and information contained herin.

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