Client Form

Fee Agreement

Review the session fee, payment, cancellation, and insurance terms.

I understand that Judyann McCarthy’s fee is $150.00 for a 50-minute individual session and $200.00 for a 50-minute couples session. Payment is due at the completion of each meeting by cash, check, or Venmo. Returned checks are the client’s responsibility, including bank charges.

I understand and agree that I will give 24 hours notice for cancellation and two weeks notice for vacation during a regularly scheduled appointment time. Missed sessions or cancellations without 24 hours notice are charged at the full fee.

If I would like to submit bills to my insurance company, I understand that I may receive a monthly or quarterly receipt to submit on my own, and that Judyann McCarthy, LCSW is not responsible for filing claims on my behalf.

I understand I have the right to receive a Good Faith Estimate explaining how much medical care will cost under the No Surprises Act.

Client name

Date

I have reviewed and understand the terms of this fee agreement.

Client electronic signature

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This page is a design preview and does not transmit client information. Final fee language and the secure signature workflow should be reviewed before launch.