Consent to Treat and Fees

I voluntarily consent to participate in coaching/mental health and/or consultation services with Juli Alvarado. Coaching is not a registered practice in Colorado and is not regulated by any authority.

Rates:

Individual or Couples phone coaching session

  • $200 for an intake/initial session, 60-90 minutes
  • $150/hour with Juli Alvarado
  • $125/hour with other staff supervised by Juli Alvarado

Office Based Counseling

  • $250 for a 1.5 hour intake/initial session, 60-90 minutes
  • $185/hour with Juli Alvarado

Home Based Therapy Services; Juli will travel to your home within a 30 mile radius

  • $295 for an intake/initial session in home, 90-120 minutes
  • $195/hour

Clinical Case Consult in Trauma Informed, Emotional Regulatory Healing: This is a teleconference service

  • $250/hour; unlimited participants, cost includes a recording of the call via mp3 audio link

Intensive Family/Couple Weekend Intervention In Home; Juli travels internationally to offer this service: Friday late afternoon-Sunday late afternoon

  • $4,500/weekend plus air travel, accommodations, rental car expense for Juli Alvarado

Organizational Consult/speaking engagement

  • $4,500/day plus expense of air travel, accommodations, rental car expense for Juli Alvarado

Intensive, experiential training for ERH practitioners: Max 20 participants

  • $15,000.00 for three intensive, experiential days of training and materials.

Training of Trainers in ERH: includes materials for sustainable training and outcomes: Max 20 participants

  • $25,000 for five intensive, experiential, on site days of training and practicum.

Payment is due at time of services. You will be invited to pay on-line subsequent to each session for coaching and therapy services. Cash and check payments are also accepted and must be made prior to the beginning of the session. Consulting and training contracts will be negotiated individually and billed after service is rendered.

An invoice will be submitted electronically subsequent to services rendered, and is due upon receipt. You will receive a link from which you can make your payment on-line.

The initial intake session fee is due prior to your session with Juli Alvarado.

Please indicate the form of payment you wish to use for this intake session rendered; we will bill for this at the time of scheduling.

The following forms of payment are accepted:  Pay Pal, Visa, MasterCard, Check and Cash

Organizations, county or state departments making referrals and payments for services for foster and adoptive families, please speak directly with Lila Sharfi in our Boulder, CO office who will arrange for invoicing and payment options.

ACG is a private pay practice and we do not bill insurance companies.

Please notify us if you plan to submit for any reimbursement from your insurance company.

At ACG we take necessary precautions to protect your personal and confidential information. These forms are kept on file in a secure location in our offices and your personal and financial information is never shared with anyone for any reason.

Please note: Beginning Jan 2, 2018;

Balances that are not paid within 48 hours of electronic invoicing will be charged to the credit card that we have on file.

I understand that I am responsible for payment at the time services are rendered.

I agree to give at least 24 business hours’ notice in the event I need to cancel or change an appointment.

For appointments on Mondays, notice of cancellation will be made by the preceding Friday.

If I fail to give such notice due to an emergency situation, the session will be rescheduled at a convenient time and no fee is charged.

I understand that if I fail to give notice and there is not an emergent situation, I will be charged half of a session fee as a late cancellation fee.

Further, I understand that if I fail to call and do not show up for an appointment I will be charged the full fee for that missed session.

ACG is a private pay firm. We do not bill for insurance reimbursement.

I understand that my insurance company will not be billed for services. I understand that cafeteria plans and HSA Cards are a type of insurance and ACG cannot bill my services off of my HSA Visa or MasterCard.

If I wish to submit a bill to my insurance provider, I understand that I am responsible for such a submission and that ACG will provide necessary documentation.

If a report, letter or consultation by an outside party is requested, including in the matter of request for records or information that you have authorized, you understand that you will be billed the usual hourly rate, in 15 minute increments, for the time needed to prepare the document, or to conduct an in person consultation. Telephone consultations will be billed at the aforementioned rate in this instance as well.

By signing this agreement you are agreeing to this policy.

WE look forward to supporting you, your family or your organization.

WE appreciate you in supporting us in this manner.

Lila Lee Sharfi,

I have read and understand the Consent for Treatment and Financial Agreement.

  • Client/Billing Information

  • Cardholder Information

    Please indicate the name and address associated with the credit/debit card you wish to use.
  • Credit/Debit Card Information

    I authorize service fees to be deducted from the credit/debit card listed here: