Financial responsibility agreement for counseling services

Financial responsibility agreement


  • Child and Family Agency (CFA) is a sliding fee scale agency. Our full fee per therapy session varies by service. Because CFA recognizes it would be a financial hardship for many clients to pay the full fee at each session, we have designed an alternative payment system, provided the client agrees to the following:

    • I agree to submit accurate financial information as requested, i.e. third party coverage, Husky, Medicare, and household’s gross weekly income minus taxes. I agree to provide the agency with other documentation of income as may be necessary.
    • I agree to provide CFA with a Husky or insurance card upon the first visit.
    • I agree to provide CFA with a signed major medical insurance form authorizing payment directly to the agency no later than my second visit and understand that I am responsible for any payment not met.
    • I understand that if my child is privately insured under a plan with a high deductible, I will be charged a $50.00 fee per session until the deductible has been met at which time a co-pay will be assessed based on my insurance plan. Should you need a fee adjustment, please discuss this with your child’s clinician.
    • I agree to pay my client fee at each visit, and if I miss one payment, I will remit payment at my next therapy session along with that session’s fee. If two payments are missed in a row, I understand I may be asked to reschedule any future appointment until payment is received. If I pay by check, I understand that I may be required to pay a $20.00 bank service charge if my check is returned for insufficient funds. Should that occur, I may be required to pay for future services in cash. I understand if my account is two or more payments in arrears, service may be suspended until such time as my account is paid in full. If you are in a financial crisis payment options are available. Below is the contact information for the billing department.
    • I agree to notify CFA promptly of any change in my financial or insurance status which may/may not affect my fee.
    • I understand that CFA has the right to request an update of my financial income information and to request validation of hardship before client fee is reduced.

    I agree to pay my patient responsibility after my insurance makes payment on services. I understand this amount is subject to change based on deductible, copayment and/or coinsurance. I understand I can contact the billing department and my clinician for questions and payment options. The billing department can be reached at (860)443-2896. If insurance coverage and Husky does not apply, a sliding scale fee will be determined by the billing department based on total household income and the number of household members.

    I have read and agree to the above applicable provisions. I understand that failure to comply with any of the above could result in service being terminated.

  • Date Format: MM slash DD slash YYYY