Claudelle R. Glasgow, Psy.D., LLC
2143 NE Broadway, #6 Portland, OR 97232
PROCEDURES AND POLICY
It is our commitment to offer services at an affordable rate to my clients. If at any time there is a change in your coverage or ability to pay, please discuss this immediately with me so that we can explore other arrangements. In signing below, I am aware of/ and agree to the following:
- I hereby authorize the release of any information necessary for third-party claim submission and/or payment for services. I authorize payment of third-party benefits to Claudelle R. Glasgow, Psy.D. for services described herein.
- The individual session fee is $180 for individuals ($250 for 90 minutes; contracted full session fee for insurance companies varies) and is requested prior to or at the beginning of the session. Sliding scale fee options may be available depending on financial need. I accept cash or credit. You are responsible to pay for all account dues before the scheduling of the next appointment.
- The session fee for couples therapy is $220. Please note couples therapy is not covered or reimbursable through insurance. If you have questions, please contact your insurance company and inquire if they cover Z63.0 Problems in Relationship with Spouse or Partner specifically.
- That this therapist may work in conjunction with some insurance companies. Session fee is set at the rate the insurance company reimburses the provider. Please check with your provider to ensure that this therapist is out of network and a bill can be provided for reimbursement. It is the client’s responsibility to ensure coverage is up to date and to submit needed documentation.
- Fees may also be charged on a pro-rated basis for other professional activities necessary for good clinical care, including related services you may need or request of me. These include time spent in letter and report writing or treatment summaries on your behalf, telephone consultation initiated by you and lasting longer than 10 minutes, and consultation time with others on your or your child’s behalf. These will be the responsibility of the client to pay. Please request my fees for testimony, chart preparation, etc. in situations where the legal system is involved.
- If you need to cancel an appointment, please do so within 24 hours of your appointment time by phone. If you do not cancel within this time or fail to show for your appointment, it will be your responsibility to pay the full session fee. Your provided credit card will automatically be charged for missed sessions or those not cancelled within time frame.
- Credit Card Name:
- Credit Card Number:
- Expiration Date:
- 3 Digit number (on back):
- I am aware that if I have not paid for services received or repeatedly cancel/not show for appointments, my/my child’s treatment may be discontinued by this therapist and legal action may be taken to obtain dues.
- I understand that by signing, I agree to stay updated and abide by updates online in all initial documentation.