Financial Agreement

For standard office-based therapy, Bridges will charge the copay or deductible of the insured client. If a client’s insurance changes, the new copayment will be charged. In the event of inability to pay copayments or deductibles, Bridges has an established sliding scale form which uses the client’s income and the current US Poverty Guidelines to determine a copayment. Forms are available from the Billing Department. Bridges also offers case management services to assist with the application process for Husky insurance.

For standard office-based therapy, payment is expected at the time of the appointment. If you have specific questions regarding your copay, deductible or sliding scale, please call (203) 878-6365 to speak with the Billing Department. We will be happy to discuss your insurance situation with you.

Home-based and school-based services do not have a client responsibility for payments. These services are fully funded by grants or insurance reimbursements received by Bridges.

Service Offered	Full Fee
Intake Evaluation	$275
Therapy - 60 minutes	$225
Therapy – 45 minutes	$150
Therapy – 30 minutes	$75
Family or Parent Therapy	$150
Group Therapy	$100
Medication Evaluation	$300
Expanded Medication Session	$175
Detailed Medication Session	$90
Intensive Outpatient Therapy (IOP)	$325

STATEMENT OF ASSIGNMENT AND RELEASE

I authorize the release of any medical or other information necessary to process all claims I may incur for services provided at Bridges.

I authorize any insurance payment to Bridges directly.

Client Name:*

First NameLast Name

Client Relationship:

I am an Adult Client or the Conservator for an Adult Client of Bridges Healthcare, Inc.I am a Parent/Guardian of a Child Client of Bridges Healthcare, Inc.

Name of Parent / Guardian or Conservator (if applicable):

First NameLast Name

Signature:*

Date*

Date