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Fee Schedule
The fee is based on a sliding
scale. Insurance is not accepted, however, this affords clients more privacy
and the opportunity to have greater control over the length of the treatment.
To determine your fee for each
50 minute session, find the row in the table below that indicates your
familyÕs total income and the column that indicates the total number of
people who live in your house. Circle the fee where the appropriate row
and column intersect. If you are a student you must base your
determination on your parentsÕ income unless you are financially independent.
Sliding
Fee Schedule (per 50-minute session)
Total Family Family
Size
Family Size Family Size
Income
(1-2)
(3-4) (5+)
_______________________________________________________
$80,000 and up
$65.00
$60.00
$55.00
$70,000 – 79,999
$60.00
$55.00
$50.00
$60,000 – 69,999
$55.00
$50.00
$45.00
$50,000 – 59,999
$50.00
$45.00
$40.00
$40,000 – 49,999
$45.00
$40.00
$35.00
$35,000 – 39,999
$40.00
$35.00
$30.00
$30,000 – 34,999
$35.00
$30.00
$25.00
$25,000 – 29,999
$30.00
$25.00
$20.00
$20,000 – 24,999 $25.00
$20.00
$15.00
$15,000 – 19,999
$20.00
$15.00
$10.00
Less than $15,000
$15.00
$10.00
$10.00
Determined Amount
of Fee : $______________________
Name
(Print)_____________________________________
Signature________________________________________
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