The below has/have either asked or specified that you have agreed to provide counseling fee assistance in some form. While we appreciate your willingness to help financially, it is our experience that it is wise to have a written agreement with you about finances for counseling. This will help us plan accordingly with the person(s) listed below for their care and the amount they will be expected to contribute to their counseling fees. Their fee is ultimately their responsibility.

Unless the below listed persons have signed a release of confidentiality we cannot specifically discuss the case or their care with you. Please note if they have signed a release so we can confirm that we have a release for the person(s) named below. It is our hope and desire that they permit us to discuss their care with you since it is our experience that including the person who is working with them, allows for greater improvement especially in areas that you are better equipped to meet their needs than we are.

If you are the one designated to pay for or approve their counseling fees you will receive a monthly bill from us itemizing their sessions and any testing. If there are specific amounts or limits to your paying for their fees such as dollar amounts, dollar amounts per session, number of sessions, or limits on what you will cover please specify below.

By submitting this document, you are signing the document electronically.

You agree your electronic signature is the legal equivalent of your manual or handwritten signature on the document. By returning the completed document using any device, means or action, you consent to the legally binding terms and conditions of the document. You further agree that your signature on the document is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature. You are also confirming that you are authorized to enter into the agreement as described by the document.