14650 Detroit Avenue, LL40

Lakewood, OH 44107

(216) 226 2721 FAX: (216) 226 2731

FEE AND SUPERVISION POLICY

Please read the following and sign below. If you have any questions, please discuss them with your counselor.

If your employer has an Employee Assistance Program, the number of sessions they have approved will be covered under their agreement.

This office will submit a completed claim form to your insurance company for reimbursement. However, you are ultimately responsible for any and all charges made in this office and all balances must be paid within one hundred twenty (120) days from time of service unless other arrangements have been made with this office. After 120 days, if you have not made other arrangements with our office, your account may be turned over to collections and fee may be assessed.

Upon request, special consideration may be extended in the event of prolonged illness, unemployment or other unusual circumstances. To avoid misunderstanding, we encourage you to discuss financial problems early. If there are any circumstances that make payment difficult, or if you have any questions regarding your account, please call Monday through Thursday, 9:00 a.m. to 4:00 p.m.

We are aware that on occasion arrangements may exist between parents for payment of services provided to their children. However, it is the policy of this office that the parent who brings the child in for treatment is responsible for the bill.

Your counselor is supervised in therapy by William L. Mock, Ph.D., #3760, LICDC, SAP, who is a licensed psychologist. It is necessary that the contents of the counseling sessions be shared with him in the course of supervision. Otherwise, all material is confidential.

I will be paying today by: (circle one) Cash Check Credit Card Insurance

___I have a $_____copay for today’s visit

By signing below, I acknowledge that I have read, understand and agree with the above policy. I authorize release of payment by my insurance company directly to the Center for Interpersonal Development.

I have been given a copy of “Client Rights.”