Dr. Bs Pay-As-You-Go Policy
This is a form that People complete in order to sign up for treatment with Dr. Beverly.  Please be advised that your responses here will be confidential.  However, in order to assist in that effort, please agree to and follow the instructions below closely.  
PLEASE Be Sure to hit SUBMIT before you exit this page so that your Response will be counted.
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CONFIDENTIAL Agreement to Dr Bs Pay-As-You-Go Policy
William T. Beverly, A.A., B.S., M.S.W. (Since 1994), Ph.D., L.C.S.W.,
Licensed Clinical Social Worker (Since 1999) & DVOMB Approved Domestic Violence Offender Treatment Provider (Since 2012)
Psychotherapy, Evaluations, Family Violence Prevention, Family Preservation, Life Skills & Advocacy
Office: 828 West 7th St., Mail: P.O. Box 871 Walsenburg, Colorado 81089 – 149 E. Main St. Trinidad --          
726 3rd St., Room #1, Sacred Heart Parish Center, Alamosa -- 739 First Ave Monte Vista
(719) 671-7793; nepeht@gmail.com; Fax: 877-359-1299
Please type in the first 3 letters of your first name. *
Please type in the first 3 letters of your last name. *
What year were you born? *
What is the date your are signing this form? *
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Where will you typically attend Sessions? *
  Throughout COVID-19, Dr. B has made many generous exceptions to previous rules in order to help Clients get through this period and their DV Treatment as smoothly as possible.  Some of these exceptions are changing as of February 21, 2022. *
Required
  Starting February 21st, 2022, Anyone who has not made a payment on their balance within the previous 2 weeks will be at risk of Suspension or Discharge.    Beginning Feb. 21, 2022, if someone has a Balance of $71 or higher, they will be suspended from attending any more treatment sessions until they bring their Balance down to below $71. *
Required
  Everyone who has a Balance should start as soon as possible to pay on their Balance and to pay on every week, or every two weeks until the balance is less than $71 by February 21st. *
Required
  If anyone has been attending sessions and does not have a voucher to cover their session; they should be making payments via the Paypal / Debit / Credit buttons on this Blog every week or at the very least, every other week.  Or with Cash (in person only).  Or mailing Money Orders or Checks in advance of sessions. *
Required
  If anyone misses a DV Session of any kind due to inability to pay, they should note that these missed sessions will count as absences and once anyone reaches the point of 3 absences (for any reason), they are subject to Unsuccessful Discharge from DV Treatment. *
Required
  From Feb. 21, 2022 forward, if anyone fails to make at least one payment every two weeks, they will be either Suspended or Unsuccessfully discharged from Treatment. *
Required
Everyone Must Learn how to Calculate Their Estimated Balance Due.   Anyone who does not currently know their their current Balance Due; yet has been attending Sessions and has not been paying for them or receiving Vouchers from their Probation Officer should be making payments already.  DO NOT WAIT for a total balance due before starting to make Payments of $35 per Session.  Starting Feb. 21, 2022, if anyone is more than 2 sessions behind in balance, they will be either Suspended or Discharged from Treatment. *
Required
Everyone is Responsible for Trying to Calculate an estimate of Their Balance Due.  Estimating Your Balance Due for Treatment is Easy:  Everyone can easily calculate  an estimate of their balance by doing the following: Add in the $100 Intake / Evaluation fee;  Add up the number of attended Group sessions; Multiply the number of attended Group sessions by $35 each;  Add together all of the Intake / Evaluation and Group Fees;  Separately add up the value of their Used Vouchers;  Add up the value of the verified Cash / Check / Money Order or Card Payments.  Then Subtract the Intake / Evaluation and Group Fees Total from the Used Vouchers.  This will give you your Balance Due. *
Required
Everyone Must Learn How To Make Their Own Payments:  All Clients who are capable of doing so will be required to learn how to make their own payments using the Paypal / Debit / Credit button on the Blog.     Here is How To MAKE CARD PAYMENTS!  If you are looking at the Blog from your cell phone:    A. Scroll to the bottom of your cell phone screen.   B. Tap where it says, "View Web Version".   C. You will see the Paypal / Debit / Credit Card Buttons in the Top-Right Corner of your screen.   D. Use your fingers to navigate and make the screen bigger.  Press you Payment Method, Put in Your Name and the Amount, and make your payments with your Card. *
Required
  If paying cash, it must be delivered directly to Dr. B. at the time of service.  If paying by check or money order, it must be received by Dr. B no later than the date of Service.  Payments are not counted until they are received.  You may hand deliver Money Orders and Checks.  Or you may mail them.  But remember, they must be received by Dr. B. prior to the Service Date.  (There is an extra $35 fee if a Check Bounces).    * Mail your Check or Money Order to Dr. Beverly at P.O. box 871, Walsenburg, CO 81089.    ** Payments are not counted unless they are received).   *** Bounced Checks and/or Insufficient Fund Card Payments will will incur a fee ($35 each). *
Required
I am going to need a Coaching Session on how to pay the Dr. B's Blog with my Debit / Credit or Paypal.  I will immediately, send Dr, Beverly a Text Message to schedule this session.  In this Text Message, I will specify which days and times I am typically available for a private 15 minute telephone call.   (If you do not request a Coaching Session, then it will be assumed that you already know how to make your payments). *
Required
I know how to reach Dr. B. and I agree to try and use Text or Email whenever possible, unless it is an emergency: Questions: Text Dr. B. at 719-671-7793 or email him at nepeht@gmail.com.  Thank you. *
Required
Please enter the following on the line below; Your Name and The Date and Time you are signing this Contract: *
Thank you for completing this form.  Be sure to click the "SUBMIT" Button so that your responses will go to Dr. Beverly.  Also, after you are done with that,  click on the X at the top right corner of your screen.  Have a nice day?
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