This agreement describes the fees and financial policies of Peaches Mindcare — Amber Faille, LCSW. Please read it carefully and bring any questions to your first session.
Fee Schedule
| Service | Duration | Fee |
|---|---|---|
| Initial Consultation | 15 min | Free |
| Initial Assessment / Intake | 60 min | $200 |
| Individual Therapy Session | 50 min | $175 |
| Extended Session | 80 min | $260 |
Other Professional Services
Services outside of regular sessions are billed prorated at [Hourly Rate] per hour. These may include report and letter writing, phone calls lasting longer than 15 minutes, consultations with other professionals you have authorized, and preparation of records or treatment summaries. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation, even if I am called to testify by another party.
Payment
Payment is due at the time of service. I accept [Payment Methods]. A card kept on file may be charged on the day of the session with your authorization.
Cancellations and Missed Appointments
Your appointment time is reserved for you. If you need to cancel or reschedule, please give at least [24–48] hours’ notice. Appointments cancelled with less notice, and missed appointments, are charged the full session fee, except in the case of emergency or sudden illness. Please note that insurance does not reimburse for missed sessions, so this charge is your responsibility.
Insurance — Out-of-Network
I am an out-of-network provider and do not bill insurance directly. Upon request, I will provide you with a superbill (an itemized receipt with the information insurers require) that you may submit to your insurance company for possible reimbursement under your out-of-network benefits. I encourage you to contact your insurer before beginning therapy to ask about out-of-network mental health coverage, deductibles, and reimbursement rates. Please note that submitting to insurance requires a clinical diagnosis, which becomes part of your insurance record.
Sliding Scale
A limited number of reduced-fee (sliding scale) spots are available for clients with financial need. Please ask — I am glad to discuss whether one is available.
Fee Changes
Fees are reviewed periodically. You will receive at least 30 days’ written notice before any fee change takes effect.
Outstanding Balances
If your account is more than 60 days past due and we have not been able to arrange a payment plan, I reserve the right to pause sessions until the balance is resolved and, as a last resort, to use a collection agency — in which case only the minimum information necessary (name, contact information, and amount owed) would be disclosed.
Good Faith Estimate
Under the federal No Surprises Act, you have the right to a Good Faith Estimate of expected charges. Please see the Good Faith Estimate Notice for details — you will also receive an individualized estimate when you begin services.
Agreement
By signing below, I acknowledge that I have read, understood, and agree to the fees and financial policies described above.
Parent / Legal Guardian (required if the client is a minor — the parent/guardian is financially responsible):