419 882-5678 info@cbhpsych.com

Please send completed form to info@cbhpsych.com and in the subject line please state the therapist you are seeing. Thank you!

    FEES: Our current fee is $200 per session. The initial session is $225. Court-related cases are $250 per session, and court testimony and travel time is $330 per hour. The duration of a session ranges from 45-60 minutes. Payment arrangements will be determined at the time of your first visit. Any changes in this agreement must be approved by CBH.

    OTHER CHARGES: We will charge for phone calls or preparation of insurance claims only if they become too time consuming. We will inform you of any such charges. Any service provided under subpoena will be charged at court testimony rates. When physical tests are administered, or if reports of any kind are prepared for another party or you, there will be an additional charge. If you are not sure if this applies to you, please ask your therapist. There will be a $35 charge for returned checks. A finance charge of 1.5% per month will be calculated on all balances over 90 days due.

    MISSED & CANCELLED APPOINTMENTS: Missed appointments and cancellations less than 24 hours prior to the scheduled appointment may result in a charge for that time. CBH maintains 24 hour voicemail and a message is sufficient notice during times when the office is closed.

    FAILURE TO PAY YOUR BILL: Financial hardships may occur to any of us. These hardships should be discussed with your therapist, so that necessary changes in your payment agreement can be made. Non-payment may result in collection efforts or legal actions. This is a regrettable action used only when other efforts have failed. If an account is sent to collection, you will be held financially responsible for all ordinary collection fees assessed to CBH.

    CONFIDENTIALITY:Information revealed in your session is confidential and will not be released to others without your permission. There are some routine exceptions to this policy. If you were referred by your physician for a consultation, we usually send information back to your physician so your complete physical and mental health can be coordinated. If your health insurance is a managed care program, we are required to provide information to them so payment for services rendered can be approved. If you have concerns about this information, please discuss it with your therapist. Some legally required exceptions to confidentiality include situations of potential harm to oneself or others, incidents of child abuse (Ohio has mandatory child abuse reporting law) and instances where a court may order records.


    PAYMENT AGREEMENT

    As a client of Central Behavioral Healthcare, Inc., I understand that I am financially responsible for professional services received by me or those for whom I am responsible. It is my intention to carry out my financial responsibility to CBH in the following manner: