Reduced Fee Agreement Form printable pdf download

DANIEL T. MERLIS, LCSW-C

REDUCED FEE AGREEMENT FORM

I have a limited number of clients I see on a reduced fee basis. This number reflects a

percentage of my practice. I am willing to see highly motivated clients at a reduced fee and for

a treatment course of ten sessions. When the client has engaged vigorously with therapy and

made significant efforts at personal change, I am willing to consider an additional course of ten

sessions when there is no waiting list and my schedule allows. We will meet for an initial

consultation at an agreed upon fee and we will discuss the possibility of working together.

By applying for a reduced fee for your treatment, you are agreeing to the limitations of ten

sessions. You also agree that I am not bound by the ten session agreement if I determine at

any time that you are non-compliant with treatment, demonstrate a lack of capacity or motivation

for treatment, or are unable to accept the treatment schedule openings I can offer you at any

particular time. You also agree that I am free to terminate treatment at any time for any reason if

I believe that the therapy is or will be unproductive or that we lack adequate rapport for effective

treatment. If your financial situation changes during the course of treatment, you agree that the

treatment fee may be renegotiated and that if you and I cannot come to agreement on the new

fee, treatment may be terminated by me. You agree that if I discover that you have been

untruthful about the financial or other information you have provided, I may terminate treatment.

Due to the very limited number of openings I have at any one time, I am not available to provide

clinical services for clients who are a danger to themselves or others, who have severe

difficulties with impulsivity or compulsivity, unstable major affective, thought or personality

disorder, a dissociative disorder, chronic problems with substance use/addictions, or who are

physically or sexually abusive to others.

In cases where I or you terminate services, I will have no further professional obligation to you

other than a referral at your request to municipal resources such as a crisis center or non-profit

counseling program.

Please describe any special circumstances or situations which affect you financially:

____________________________________________________________________________

What fee do you believe you can afford? _________________

By signing this form, you are indicating that you understand and agree to the policies as

stated above and that the financial information provided is accurate.

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Signature

Date

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Printed Name

Reduced Fee Agreement Form