Capable Hands and Associates
Letter of Agreement
Re: Therapy services
For: D.O.B:
Address:
Please read and sign this letter of agreement and complete Intake form prior to our first meeting. In addition, we would appreciate any other recent evaluations pertaining to your child prior to our first meeting. This will allow us to more effectively provide services.
Our first meeting will be approximately one hour. We will meet with you first to review your concerns, objectives and/or assessments regarding your child. Then we will complete some preliminary assessments and/or observations of your child. After that we will discuss the need for additional evaluation and/or treatment options.
Our initial consultation fee is based on a fixed hourly rate to be discussed at the time of the intake interview. It is based on the phone interview, review of intake form, background information, and evaluations, as well as the initial visit.
Subsequent treatment visits are charged at an agreed upon rate. A fee of $50 will be charged if you cancel with less than 24 hours. If a therapist arrives at your house for a pre-arranged visit and you are not there, we will have to charge the full hourly fee.
If we are pursuing a more comprehensive evaluation the cost will be charged at agreed upon rate per contact hour and two hours for report writing.
Payment is expected at the end of each visit and after the completion of the evaluation report, if one is generated. If any check is returned for insufficient funds, you will be charged any additional fees that are subsequently incurred.
We are looking forward to meeting with you and your son/daughter on _________________________________________________________________dates.
I the undersigned have read, understood and agree to the terms of this agreement: ______________________________________________Date: ___________ Print: ______________________________________________________________________
Therapist: ________________________________________________ Date: ___________