Simple Fee Agreement Template for Private Practice
Money is part of the therapeutic frame. A clear Fee Agreement prevents awkward conversations later. It ensures the client knows exactly what they are paying, when, and how.
TL;DR
- Keep it Simple: One page maximum.
- Include: Rate per session, payment timing (time of service), and accept payment methods.
- Add-ons: Explicitly state costs for letters, court appearances, or extended sessions.
- Updates: Include a clause that rates may increase with notice.
One-Page Fee Agreement Template
(Copy and paste into your practice documents. Disclaimer: This is for educational purposes and does not constitute legal advice. Consult a local attorney.)
FINANCIAL AGREEMENT & FEE SCHEDULE
Practice Name: [Your Practice Name] Provider: [Your Name, Credentials]
1. FEÈS FOR SERVICE The following fee schedule applies to all services provided:
- Individual Psychotherapy (50 mins): $[Amount]
- Couples/Family Therapy (50 mins): $[Amount]
- Intake/Initial Consultation (60 mins): $[Amount]
- Phone Calls (over 10 mins): $[Amount] per 15-min increment
- Letters/Report Writing: $[Amount] per hour (min 30 mins)
2. PAYMENT Payment is due in full at the time of service. We accept: [Credit Cards / HSA / Cash / Check]. A credit card MUST be kept on file to secure appointments.
3. INSURANCE (Out-of-Network) I am an out-of-network provider. I do not bill insurance directly. I will provide you with a monthly "Superbill" upon request, which you may submit to your insurance for potential reimbursement. You are responsible for knowing your out-of-network benefits.
4. LATE CANCELLATIONS & NO-SHOWS Cancellations made with less than 24 hours' notice will be charged the full session fee. This fee is NOT covered by insurance.
5. OVERDUE PAYMENTS If a payment method is declined, the client must provide a new payment method before scheduling future sessions. Balances over 30 days old may incur a 5% late fee.
6. RATE CHANGES Rates are subject to change. Clients will be notified in writing at least 30 days prior to any fee increase.
ACKNOWLEDGEMENT: I have read and understand the financial policies above. I agree to pay for services rendered.
Client Signature: __ Date: __
Where to Place This Form
- Intake Packet: Should be signed alongside HIPAA forms before the first session.
- Booking Page: If you charge standard rates, list them clearly on your OnlyCaly booking page descriptions so there are no surprises.
- Website: Have a "Rates & Insurance" page (even if it just says "Contact for rates").
Handling "Add-On" Fees
Therapists often forget to charge for effective time spent outside the session.
- Court Appearances: These are draining. Charge a premium (e.g., $300/hr) and require a retainer.
- Paperwork: "I charge my hourly rate pro-rated for any paperwork taking longer than 15 minutes."
- Between-Session Crisis Calls: Define if these are billed. "Calls under 10 minutes are free; over 10 minutes are billed at $X."
Common Pitfalls
- Sliding Scale Ambiguity: If you offer a sliding scale, create a separate "Sliding Scale Agreement" that specifies the temporary rate and when it expires/renews.
- "I forgot my wallet": This is why you keep a card on file (Stripe/Square) in your HIPAA-compliant software. You charge it automatically at the end of the day.
FAQ
Can I charge a credit card fee? In some states, it is illegal to charge a surcharge for credit cards. It is safer to raise your overall rate by 3% to cover merchant fees rather than adding a line item surcharge.
Do I need a new agreement if I raise my rates? Technically, yes, or at least a signed notice acknowledging the change. An email trail is often sufficient, but a signed update is safer.
Handle Payments Automatically OnlyCaly integrates with Stripe to collect payments and deposits instantly when clients book. No more chasing invoices.
