FINANCIAL AGREEMENT

This form breaks down the costs and payment information and has you confirm a couple things.

In the email Kimberleigh sent with the link to this page, you will also find a copy of your Good Faith Estimate. The Good Faith Estimate is part of the No Surprises Act law, which gives you the right to receive as estimate of the cost of your treatment when you're not using insurance benefits. The estimate you received is for the intake appointment itself. During the intake we will discuss how often we plan to meet and then I will provide you with an updated one for ongoing therapy services over the course of this calendar year. The cost estimates provided are based on the same rates shown in the Financial Agreement. You don't need to print or sign it, there is a spot in the Financial Agreement where you mark to acknowledge you've received it.

If you have any questions or need to reschedule your appointment, you’re welcome to send an email to khagar@mindfullybalancedtherapy.com or call/text (847) 447-2919.