Financial and Appointment Agreement
JoMo Counseling is a non-profit organization and suggests a donation rather than charges a fee. The IRS
declares that any donation for which services are received is not tax-deductible. If a non-family friend or
organization is paying for your counseling, the donation will be tax-deductible for them.
Most of our clients pay the full suggested donation. If you cannot make the suggested donation, you must
inform the secretary or therapist before starting therapy. Some type of donation is required towards each
visit. Please tell us the amount of the donation you can make. If JoMo Counseling has funds available to cover
the difference, counseling may begin. If not, your name will be placed on a waiting list. As funds become
available, you will be contacted and counseling can begin.
1. The suggested donation for a 50-minute session is $100.00. Any scheduled appointment will be
billed at that amount even if the session is shorter. Any time over 50 minutes has a prorated donation
based on that scale. For example, for a 60 minute session the suggested donation is $120.00: for a 70minute session, $140.00.
2. Clients sometimes need to talk to a therapist via telephone. No donation is suggested for telephone calls
up to 5 minutes in length. A donation based on the rate for counseling is suggested for longer calls.
3. The suggested donation for texts to the counselor is $1/line whether sent or received by the client.
JoMo Counseling recommends that “texting” be minimized as it is a less effective means of
communicating important information. Texts to confirm appointments are free.
4. Sessions or telephone calls that occur after regular business hours or are emergency situations that
require interruption of scheduled appointments will have a suggested donation 1.5 times the regular
donation described in #1.
5.
The full payment is received at the end of each session unless prior arrangements have been
made. Payment may be made by check, cash, money order, or credit (Mastercard or Visa) or debit card.
Phone calls or text messages will be paid for at the next session.
Missed/Canceled Appointments: Each appointment made is a mutual commitment by both the client and the
therapist. If for any reason the client cannot make the session, s/he must call at least 24 hours in advance to
cancel. If not, the full donation for the 50-minute session will be suggested. A 48-hour notice is requested for
Monday appointments. Leaving a message on the JoMo phone is sufficient.
Client Statement: I/We have read and understand the above. If I/We had any question, I/We have received a
satisfactory explanation. I/We committed to donate $_______ per 50 minute session and a pro-rated amount for
any time over 50 minutes (This cannot be zero or left blank).
____________________________
(Signature)
________________________
(Date)
____________________________
(Signature)
_________________________
(Date)