FEE AGREEMENT

I agree to be responsible for the following charges, and I am aware that no progress or completion, paperwork will be released to me or to any third party until I have paid my balance in full.

AMOUNT TOTAL SERVICE CLIENT WAIVED
PER INITIAL (Staff Initial)
Total Intake Fee
Total Evaluation
Total Level I Alcohol and Drug Awareness Program
Total Level I Alcohol Education (Driving Offense)
Session Anger Management
Total Cognitive Skills
Session Conflict Resolution
Session Domestic Violence
Session Family Therapy
Session Individual Therapy
Session Level II Alcohol Education
Session Level II Alcohol Therapy (Intensive)
Session Level II Alcohol Therapy
Session Marriage/Couple Counseling
Session Parenting Skills
Session Substance Abuse and Dependency
Session Women's Group
Other
Monitor Antabuse Monitoring
Visit Antabuse Physical
Test Breath Analysis Testing
Test Urinary Analysis Testing

I understand that if I miss a session, I must call before the session and get approval in order to be excused. I understand that I will be charged $10.00 per each unexcused absence. Fees must be paid at or before the time of service. Services will not be rendered without payment. (You will not be allowed to attend group/individual sessions if you do not have payment). Unless you have made other payment arrangements. You will guarantee that payment will be made in compliance with those arrangements. Failure to do so, it will void original arrangement, then fees must be rendered for services. Please be advised that any outstanding unpaid balances over 30 days will be reported to an outside collection agency.

I understand that if the courts/probation are paying for my classes, I am still responsible to pay for any random testing or unexcused absences I acquire throughout the treatment process. Adult/Youth Services, LLC., I understand that my signature does not bind me to treatment, but it does make me responsible for charges incurred prior to my termination.

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