Clinical Counseling Contract & Practice Policies - Private Couples Retreat Program

Terms & Conditions

Click here to read all terms and conditions before completing the form.

Client Information

Name *

First

Last

Email *

Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Information

Name *

First

Last

Phone

Relationship

Agreements

Agreed upon fee *

Rates:
Individual - Initial Consultation (or weekly and bi-weekly counseling)
San Marcos - 1 hr 30 mins - $262.00

Individual Psychotherapy (weekly or bi-weekly)
San Marcos - 1 hr - $175.00

Initial Consultation: Private Couples Retreat & On-going: Couples Sessions
San Marcos - 2 hrs - $400.00 ($200/hour)

Option A: 2 Day Private Couples Retreat
San Marcos - 12 hrs - $2,400.00

Option B: Day Private Couples Retreat
San Marcos - 4 hrs - $800.00

Good Faith Estimate Rates
Full Private Couple Retreat Program (14 hours total, all services, one time per year)
$2,600.00

I give permission to communicate via email according to email policy listed. *

I give permission that a bookkeeper can have access to my non-clinical information (e.G., name, dob, address, email). *

I give permission to a bookkeeper to email statements to address that I provide. *

I would prefer hard copy invoicing. *

I have read and agree to the Terms of Service.

Click here to review the Terms of Service.

Your Signature *

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