FINANCIAL DATA FORM

To assist your psychotherapist in setting a fair fee, please complete the information below. Please feel free to discuss this material with your psychotherapist. This information will help to set a fee for regular psychoanalysis/psychoanalytic psychotherapy.

Total number of members in household: _________________________________________________ Medical Insurance: Yes ___ No ___ Insurance Company: ___________________________________ Annual wages, salaries, tips, etc. ____________________ Financial Assets: ___________________ Interest income: ___________ Dividends: ____________ Misc. income: _____________________ Total household income: ____________________________________________

If you are not sure of the above categories, you can estimate and request another form when you have more accurate information. Fee: Signed: _____________ _______________________________ Date: ___________________________

Patient name (please print): ________________________________________________

Name Address Ph. Fax SCHEDULING AND FEE POLICY Please read and discuss this information with your psychotherapist. Sign below to indicate that you understand and accept this policy. 1. Regular (at least once weekly) sessions are essential to a constructive therapeutic process. The time set aside by you and your psychotherapist is your time and part of the therapeutic process. 2. The fee per session is $ ___. In special circumstances or if you have two or more weekly sessions, the fee may be adjusted upon request. Fees are subject to change. 3. Payment for each session is due by check or cash at the end of each session. 4. Cancellations. A session fee will be charged for sessions cancelled less than 24 hours in advance. Sessions cancelled at least 24 hours in advance may be rescheduled within a week if your psychotherapist has an alternative appointment available. If not, a session fee will be charged for the missed session. No fee is due for up to 2 weeks of vacation per year taken by the patient if announced at least 1 week in advance. 5. If requested, a bill for services rendered can be provided on a monthly basis. Payment of fees is not dependent on insurance reimbursement. Your psychotherapist does not accept assignment of insurance benefits. Your thoughts and feelings about fees and scheduling are important to your psychotherapist and to your growth in psychotherapy. Please discuss all of your reactions with your psychotherapist. Signed: ______________________ Date: __________ Patient Name: _____________________