Cost Sheet – Psychological Therapy

Record #

Cost Sheet – Psychological Therapy

Fees

  • Psychological therapy sessions are billed at the rate of _______________ per session for sessions with a duration of up to fifty (50) minutes. Longer sessions are billed at an extra CAD$50.00 per additional ten (10) minutes or fraction thereof.
  • Phone calls, letters, messages, e-mails, text messages, and/or any other contacts by you or on your behalf, for reasons other than for making, changing, or cancelling appointments, are billed to you at the rate of CAD$50.00 per ten (10) minutes or fraction thereof. Minimum charge is CAD$50.00.  Insurance companies and other third-party payers typically do not cover these services.
  • Any other services provided to you or yours are not included in the psychological therapy sessions. Examples of those services are, but not limited to, management of emergencies, crisis intervention, contacts and/or consultations by telephone, in person, or by any other means, by you or on your behalf, and/or interviews made with you or on your behalf, reports you request for yourself or other parties, copies of files, and the administration, processing, interpretation, and reporting of psychometric tests.  These additional services will be charged based on our standard fees, and billed at the rate of _______________ per fifty (50) minutes, with an extra CAD$50.00 per additional ten (10) minutes or fraction thereof.  Minimum charge is CAD$50.00.
  • If using insurance or a third-party payer, you agree to pay for any charges not fully reimbursed by the insurance company or the third-party payer.
  • All payments by check are to be made to the order of Angel Enrique Pacheco, Ph.D., C.Psych. or Dr. Angel E. Pacheco.
  • A fee of CAD$100.00 will be charged for NSF or returned checks.
  • All services rendered are due and payable in full, in cash, by check, or by an electronic transfer of funds, on the occasion of the delivery of each unit of service, unless otherwise agreed-upon in advance.
  • If we agree you will pay for services rendered by means of an electronic transfer of funds, please ask us for the password to use, and ensure that the electronic transfer of funds is made to the order of apacheco [AT] idpp [DOT] org on the same day of the delivery of each unit of service, as your account will become overdue otherwise.
  • The account will be considered overdue when not paid in full on the date of the delivery of the last unit of service, unless a prior, different arrangement is approved, and payments are made as agreed.  Failure to make any agreed-upon full or installment payment on the due date will cause the account to become overdue immediately.
  • Interest on overdue accounts will be charged at the compound rate of 1.5% per month or fraction thereof.
  • Legal services and/or debt collection agencies will be employed to collect overdue accounts, at the expense of the debtor.

Missed Appointments

  • All missed appointments will be billed at the specified rate of _______________ per session, unless notice of cancellation is received twenty-four (24) hours in advance, excluding weekends and statutory holidays. Please note insurance companies and other third-party payers typically do not cover missed appointments.

Photocopies

  • The fee for photocopying is set as per the Guidelines for Fees and Billing Practices of the Ontario Psychological Association.

Court Testimony

  • In the event that Dr. Pacheco, his Assistants, and/or Associates are required to attend a Court, for whatever reason related to you or your significant others, current, past or future, you hereby consent and agree to pay Dr. Pacheco a separate fee, billed at the rate of _______________ per hour or fraction thereof, for consultations, preparation, travel, and attendance time waiting, and/or testifying in court.
  • A minimum per diem fee of _______________, plus fees for the above-cited items, will apply.
  • Court-related fees shall be paid by the undersigned in advance or in terms negotiated at the time of the call/contact.
  • Three (3) business days advance notice is required for a cancellation for appearance in Court, as otherwise the minimum per diem fee for one (1) day will apply.
  • In the event of a cancellation for appearance in Court, consultations, preparation, travel, and other related services in course or completed will still apply.

Consent Agreement: By signing below, you indicate that you understand and agree to the nature and purpose of this psychological therapy, to each of the points listed above, and acknowledge receipt of a copy of this document.

ACCEPTED IN ACCORDANCE:

Printed Name                                                             Signature                                                             Date

 

 

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