Client-Counselor Service Agreement

Welcome to Compassionate Counseling Services LLC. This document will serve as an agreement and disclosure of my professional services and policies, as well as summary information about the Health Insurance Portability and Accountability Act (HIPAA). When you sign this document, you consent and agree to the terms laid out below.

Counseling is a relationship that relies on the rights and responsibilities between two parties/persons. As our client in counseling, you have rights and responsibilities you are entitled to, as well as legal limitations. In the same way, we have corresponding responsibilities to you, too.

Goals of Counseling

Counseling can have varied goals, depending on the person. Whatever the case, we are obliged to help you accomplish those to the best of our abilities. We can offer suggestions but you get to decide where, what, and how you want to reach your goals.


Counseling may be a different progress for everyone. So, we highly encourage you to actively participate in your treatment for best results. Appointments will typically be within 45 minutes but this can change depending on agreed terms. Should you need to cancel, please inform us within 48 hours. If you are unable to do so, you will be charged for the full session.


We are bound to make every effort to keep your personal information private. Should there be any discrepancies or you wish to release your information, we will ask you to sign a consent form. Also, we may have to release information to third parties for consultation with other healthcare professionals to give you the best services but your personal information will not be disclosed. Similarly, for state and federal laws, we may be bound to release information on the grounds of potential harm to yourself and others.

Fee Schedule:

  • 90791 Psychotherapy diagnostic evaluations (Intake) – $160
  • 90834 Psychotherapy 45 minutes – $120
  • 90837 Psychotherapy 60 minutes – $160
  • 90847 Family and Couples Counseling – $120
  • 90853 Group therapy 90 to 120 minutes – $45
  • 90839 Crisis Counseling – $160
  • 45 minute Individual Session
  • $30,000 (Yearly) and below $40.00
  • $30,001 (Yearly) to $50,000 $50.00
  • $50,001 (Yearly) to $70,000 $75.00
  • $70,001 (Yearly) to $90,000 $100.00
  • $90,001 and above $150.00
  • 1.5 to 2 Hour Group Session
  • $30,000 (Yearly) and below $20.00
  • $30,001 (Yearly) to $50,000 $30
  • $50,001 (Yearly) to $70,000 $40
  • $70,001 (Yearly) to $90,000 $60

$90,001 (Yearly) and above $80


If you have health insurance, we can assist you during the filing of claims and acquiring information but you are still responsible to know your coverage and other pertinent information. Some health insurance companies may also authorize us to send them a clinical diagnosis, and for which, by signing this agreement, you agree for us to do so.

Consent to Counseling

Please indicate your signature below if you agree to the terms set above.

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