Sliding Fee Schedule

Sliding Fee Scale for Counseling Costs

Annual Gross Income                          Sliding Fee Scale

$60,000 + …………….……………….. $90 (includes 1 Pro-bono appointment)

$25,000 – $60,000…………………… $60 (includes 1 Pro-bono appointment)

$25,000 or less……………………… $35 (includes 1 Pro-bono appointment)

All CDA (Intake Appointments) $99.00

Sliding fee scale is available for all cash clients seeing mental health practitioner, or licensed mental health professional. Fees agreed upon under previous slide fee scale charts will remain in effect and be honored for the duration of client’s time with Brighter Future Health, Inc. Sliding Scale is based on the honor of the client. Proof of income may be required including SSI or SSD approval letters, pay check stubs, or income tax returns. If any changes arise in income, please notify Brighter Future Health, Inc so adjustments can be made to the fee. Sliding fee clients pay the same rate for an intake session. Fees above are based on a regular 45 minute session.

 

SLIDING SCALE FINANCIAL AGREEMENT

 

By signing below I agree to the above fee schedule and understand payment (cash, check) is due in full at the beginning of each counseling session.

Please Initial Below:

_____ I agree to pay a fee of $10 plus the amount of the check for any returned checks.

_____ I agree to cancel the appointment at least 24 hours in advanced, if I can’t make an appointment.

_____ I understand that if I no-show to an appointment, I am subject to a $10 rescheduling fee.

The agreed upon fee per 45-minute session is ________________

Comments or notes about fees or fee arrangements:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Please Sign Below:

Client: _______________________________________________ Date: __­­______________

Parent/guardian: ______________________________________ Date: ________________

Brighter Future Health _________________________________ Date: ________________