Request for Services

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CLIENT DEMOGRAPHICS

Name of Client *

First

Last

Client Date of Birth *

Sex *

Female Male

Address *

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City

State

Zip Code

Country

Email *

Phone Number *

REQUESTED SERVICES

Service(s) Requested *

Individual Adult Counseling (18yo +) Youth/Adolescent Counseling Couples/Family Counseling Individual Therapeutic Coaching Couples/Family Therapeutic Coaching Other (i.e. Acupressure, MBSR, Ministerial, NLP, Reiki)

Specify "Other" Service(s) Requested *

Site Preference (Choose One) *

Goals/Expectations

Briefly Identify Goals/Expected Outcomes *

Therapeutic Life Coaching Disclaimer

THERAPEUTIC COACHING is not psychotherapy, however, it does utilize components of evidence-based psychotherapy interventions such as Cognitive Behavioral Therapy, Motivational Interviewing, and Solution-Focused Therapy. These psychotherapy interventions are integrated with evidence-supported techniques such as Mindfulness, Meditation, Neurolinguistic Programming, Emotional Freedom Technique, Positive Thinking, and Visualization to help clients master attitudes, build skills, and accomplish tasks to reach specific life, career, and/or relationship goals. The Therapeutic Life Coach may very well have the education, training and credentials of a psychotherapist, however, in their capacity as Therapeutic Life Coach, they are not functioning as a clinical therapist.

THERAPEUTIC COACHING sessions are scheduled in blocks of 30 minutes at the discretion of the client. The client accepts that they are responsible for engaging with the coach at intervals that ensure their success within a reasonable time frame as determined by themself and the coach.

Once per week between sessions text or email check-ins and assignment reviews are included in quoted Therapeutic Life Coaching service fees.

RATES and PAYMENTS
Payment is due at the time of service. Please indicate preferred payment method so our office may provide appropriate credentials and instructions for making your payments. You may always change your preference later.

STANDARD RATES

COUNSELING
(covered by insurance; check your policy)

Individual
$200/Session Hour
Sliding Scale $65 and up

Couples/Family
$250/Session Hour
Sliding Scale $80 and up

THERAPEUTIC LIFE COACHING
(not covered by insurances)

OTHER SERVICES
(not covered by insurances)

Individual
$35/30 Minute Session
$65/60 Minute Session
$25/15 Minute (or part of) Additional Time/Services Requested

Couples/Family
$50/30 Minute Session
$80/60 Minute Session
$25/15 Minutes (or part of) Additional Time/Services Requested

Acupressure, Reiki, NLP
$65/60 minute session

Mindfulness Based Stress Reduction
$30/hour

Ministerial
TBD

Preferred Payment Method *

I will provide credit/debit card account to be kept on file and charged upon delivery of service I will pay at each session (cash, credit/debit, CashApp, Venmo, PayPal) Please bill my insurance (not applicable to coaching services)

Member ID # of Primary Insurance (enter N/A if insurance is not being used) *

Name of Primary Insured (enter N/A for no insurance) *

First

Last

Primary Insured's Birthdate *

Relationship to Client *

Primary Insured's Address (if different than client's) *

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City

State

Zip Code

Country

Member ID # of Secondary Insurance *

Name of Secondary Insured *

First

Last

Relationship to Client *

Secondary Insured's Birthdate *

Address of Secondary Insured (If Different Than Client's) *

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City

State

Zip Code

Country

TERMS AND CONDITIONS FOR USE OF INSURANCE:
The client gives Monarch Therapeutic Services LLC/Beverly T Chevalier, LCSW permission to release information to/receive information from insurance plan for the purposes of coordination of services and payments. The client understands that they are responsible for letting Monarch Therapeutic Services, LLC know of any changes to their insurance. The client understands that they are responsible for payment services that their insurance company denies payment for. The client understands that they are responsible for any deductibles, out-of-pocket expenses, and/or other charges that their insurance plan does not cover.

Upon submitting this form, the client/insured agrees to the above terms and conditions for use of insurance. *

Agree Not Applicable

TERMS AND CONDITIONS OF SERVICES:
If the client fails to appear for an appointment without a 24-hour notice of cancellation, the session fees will be charged in full. If the client arrives late to their session, the session will end at the time originally scheduled and the client will be charged the full fee for the session. If the client arrives more than 10 minutes late for their scheduled appointment and did not make prior arrangements with the coach, their appointment may be forfeit. If the appointment is forfeit, the client will be charged the full fee for the session. Services outside of those specified in this agreement (including, but not limited to, phone calls, emails, record reviews, and professional consultations) at times other than the scheduled session are the client’s responsibility. These services will be billed at $25 per 15 minute increment.

UPON SUBMITTING THIS FORM THE CLIENT AGREES TO THE ABOVE TERMS AND CONDITIONS OF SERVICES *

Agree

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