SOAR Program Fee Agreement
Name: Date of birth:
Center for Family Development (CFD) agrees to provide services based on the assessed needs of the client. Services may include:
Select one: Intensive TreatmentAftercareSelect applicable Mental Health payer(s): Commercial Oregon Health Plan (OHP) NoneIndigent SOAR Contract: YesNoClient Responsibility per Session: Individual/Family Sessions: $ Groups: $
For services not covered by a Mental Health or Offense Specific Payer listed above, the individual/guardian will be responsible for the following:
The client agrees to and understands the following statements:
The client has read and understands this form. They have had the opportunity to ask questions.
By signing below, I acknowledge that I have read and understand this form, have had the opportunity to ask questions, and agree to the above fees and responsibilities.
This document is being signed by: ClientPersonal Representative, see below
If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.
Full legal name of Personal Representative:
Relationship to client:
Definition of Personal Representative:For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: SOAR Program Fee Agreement
Agree & Sign