WESTSIDE PSYCHOTHERAPY
313 Price Place, Suite 208
Madison, WI 53705
(608) 236 4460 (608) 236 4461 fax
FEE AGREEMENT
At Westside Psychotherapy, the fee for a 50 minute hour of individual or couples psychotherapy is $140.00, and for a 60 minute hour it is $150.00. The full 60 minute hour is highly recommended for couples. For those choosing to pay out of pocket, if there is financial need, the fee can be reduced to a minimum of $115.00 for a 50 minute hour, or
$125.00 for a 60 minute hour.
If you wish to use insurance, it is your responsibility to ascertain the limits of your insurance payments for psychotherapy, confirm that your therapist is on the appropriate panels, acquire preauthorization as necessary, and pay for any applicable co-pay fees.
You must keep track of your approved number of sessions and sessions used.
If you wish to continue treatment after your insurance benefits have been exhausted, Westside Psychotherapy’s standard fee structure applies.
It is your responsibility to inquire about your coverage. Payment or co-pays are expected at the time of service, and checks can be made out directly to your individual provider. We are happy to accept cash, check, PayPal, debit, Visa or Mastercard.
Appointments that are missed or canceled with less than 48 hours (TWO
BUSINESS DAYS) notice will be billed at full fee. Fees for missed or late-canceled appointments will be payable by the next scheduled appointment. PLEASE NOTE:
Insurance does not cover missed appointments. If using insurance for your therapy, YOU
WILL BE PERSONALLY RESPONSIBLE for paying these fees.
I have read and agree to the above stated policy.
___ I choose to pay directly at the rate of $_______ per ___ minute session.
___ I choose to use my insurance if services at IPA are covered, and will pay any co-pay.
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