Financial Responsibility Please read, check each box and sign where indicated – this document describes your financial responsibilities.Please consent to the following:* I understand that payments for all services are due at the time services are rendered. Koppa Counseling accepts credit cards/debit cards, personal checks, Zelle, and cash. (Venmo and American Express are not accepted)** I understand that my insurance policy is a contract between myself and the insurance company. Koppa Counseling is not contracted with any insurance companies and does not accept any insurance.** I understand that my insurance company may not approve or reimburse me for services from Koppa Counseling. Koppa Counseling will not become involved with disputes between me and my insurance carrier.*The current fee structure is as follows: Intake assessment: 60 minutes 250.00 Individual therapy: 60 minutes45 minutes 225.00195.00 Group therapy: 60-90 minutes 95.00 per group Family therapy: 60 minutes 225.00 Parent consultation: 60 minutes 225.00 Telephone consultation: 10-19 minutes20-29 minutes30-45 minutes 75.00125.00175.00 Dr. Koppa does do not charge for telephone consultations that are less than 10 minutes. Should it become apparent that additional sessions are indicated, we will increase the number of weekly sessions as needed. * I understand all charges are my responsibility whether my insurance company pays or does not pay.*legal action* I understand if legal actions occur in which Dr. Koppa is requested or subpoenaed to provide testimony (such as a custody case), I will be responsible to pay Dr. Koppa directly for her services for providing the following: (a) the time spent preparing for court, (b) the time spent for transportation to/from court, and (c) the time spent appearing in court. Charges for legal services will be billed at $ 500.00 per hour. This fee is NOT reimbursable by a Third Party Payer and is therefore the full legal responsibility of the client and/or the client’s parent or legal guardian.*By signing below, I acknowledge that I have read and I understand Koppa Counseling's financial policies and I accept responsibility for payment of any fees associated with my care.* I Accept Client Name*Please enter your full name in the textbox below to accept the policy: * I understand that by typing my name and clicking on "Submit", I am electronically signing this document.