SOAR Program Fee Agreement

1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Sex Offense Adult Recovery (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:

Intensive Treatment

  • A minimum of two 1-hour individual sessions per month. Services may be offered more often as therapeutically indicated. If more sessions are indicated, this will be discussed with the client.
  • Weekly groups for two hours.


  • The frequency of services will be determined collaboratively between you and your therapist.

Select one:

CFD will submit claims to appropriate payers for services provided. I agree to and understand the following statements:

  • I will inform CFD of any changes in coverage as soon as possible. If I am covered by a payer for which coverage ends for any reason, I may be responsible for the full cost of treatment.
  • CFD will provide a monthly statement listing services, payments and adjustments for the previous month that are my responsibility. The statement will specify an amount due, if applicable. Fees are due on the 25th of each month.
  • Failure to keep the account current may result in suspension from the program. If suspended, the individual/guardian must ensure that the account balance is paid in full ($0 balance) for reinstatement into the program. In this event, reinstatement will occur on the first of the month following the month in which the balance was paid in full.
  • CFD accepts payment by cash, check, VISA or Mastercard owed by the individual/guardian.
  • Payment for costs not covered by insurance are due at the time of service.

Mental Health (MH) payer(s): 

Bill client responsibility to:

Offense Specific (OS) payer(s):

Client Responsibility per Session: Individual/Family Sessions: $      Groups: $


No MH or OS payer(s): SOAR Monthly Fee:

Non-Administrative Rates:

For services not covered by a Mental Health or Offense Specific payer, client responsibility per session:

  • Assessment: $200.00
  • Individual/Family Session: $100.00 ($25.00 per 15 minutes)
  • Group: $50.00
  • Case Management: $50.00 ($12.50 per 15 minutes)

Medicare/Commercial Insurance:

  • I have the responsibility to contact the payer(s) to verify coverage and benefits.
  • I am responsible for any cost that is not covered by the payer(s). This does not include any portion that is the contracted discount with the payer(s).
  • If treatment requires or if I choose to exceed the number of visits the payer(s) has authorized, I will be responsible for payment of services exceeding authorized amount. Additionally, there may be additional costs incurred related to treatment not covered by Medicare/Commercial Insurance that cannot yet be estimated, such as consultation and case management services; these costs will become my responsibility.
  • Unless otherwise specified by the payer(s) during CFD's initial benefit check, I understand that I will be responsible for paying an amount of $25 at the time of service until CFD receives further information from my payer(s).
  • If CFD is out of network with the payer and/or if the payer does not cover the service provided, I will be responsible to pay for any charges. If the payer compensates CFD for any portion of these costs, CFD will then reimburse me the amount paid by the payer.
  • If I am covered by a secondary payer, I must provide all necessary information of the secondary payer to enable CFD to submit claims, as a courtesy to me.

If applicable, I authorize billing to my insurance company and payment of medical benefits directly to CFD. I authorize CFD to provide information to my insurance company that is necessary to complete this billing process.

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:

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:

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Signature Certificate
Document name: SOAR Program Fee Agreement
lock iconUnique Document ID: 7a217776f8a6fe327f8341424e60b65ce5f1a005
Timestamp Audit
December 29, 2020 8:04 pm PDTSOAR Program Fee Agreement Uploaded by Do Not Reply - IP
December 30, 2020 8:09 am PDTCFD Main - added by Jason Dooley - as a CC'd Recipient Ip:
January 14, 2021 3:25 pm PDTCFD Main - added by Jason Dooley - as a CC'd Recipient Ip:
March 18, 2021 2:56 pm PDT Document owner has handed over this document to 2021-03-18 14:56:39 -
March 18, 2021 2:56 pm PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip:
May 3, 2021 8:47 am PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip:
March 6, 2024 2:41 pm PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip: