Fee Agreement & Consent to Treat
I voluntarily consent to participate in coaching/counseling and/or consultation services with staff at The Alvarado Consulting and Treatment Group.
Coaching is not a registered practice in Colorado and is not regulated by any authority. All of our staff are licensed counselors in the state of Colorado and offer both counseling in Colorado and Coaching Internationally.
Simply Healing phone coaching session
Simply Healing office-based psychotherapy
Home-Based Therapy Services;
Our staff will travel to your home within a 30-mile radius
Clinical or Organizational Consult in Trauma-Informed, Emotional Regulatory Healing: This is a teleconference service
Intensive Family/Couple Weekend Intervention In Home; Our staff travels internationally to offer this service: Friday late afternoon-Sunday late afternoon
Organizational Consult/Training/Speaking engagement
Intensive, experiential training for ERH practitioners: Max 20 participants
TOT: Training of Trainers in ERH: includes materials for sustainable training and outcomes: Max 20 participants
Payment is due at the time of services. You will be invited to pay online subsequent to each session for coaching and therapy services. Venmo, PayPal, 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 subsequent to service 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 online.
The initial intake session fee is due prior to your session.
Please indicate the form of payment you wish to use for this intake session; we will bill for this session only at the time of scheduling.
The following forms of payment are accepted: Venmo, PayPal, Visa, MasterCard, Check, and Cash
Organizations, county, or state departments making referrals and payments for services for foster and adoptive families, please call 720-294-4929 and we 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 and your personal and financial information is never shared with anyone for any reason.
Please note: Beginning Jan 2, 2022;
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 the necessary documentation.
If a report, letter or consultation by an outside party is requested, including in the matter of the 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.
I have read and understand the Consent for Treatment and Financial Agreement.
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If you have questions about the contents of this document, you can email the document owner.
Document Name: Fee Agreement & Consent to Treat
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