SOAR Program Fee Agreement


Center for Family Development

1258 High Street, Eugene, OR 97401 - 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.

Aftercare

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

Select one:
Select applicable Mental Health payer(s):
Indigent SOAR Contract: 
Client 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:

  • Assessments: $130.00
  • Family Therapy without Client Present: $100.00
  • Individual Therapy: $100.00
  • Case Management/Consultation: $40.00
  • Family Therapy with Client Present: $120.00
  • Groups: $50.00
  • Additional Info:

The client agrees to and understands the following statements:

  • There may be other costs incurred related to treatment that cannot yet be estimated, such as polygraphs, risk assessments, consultation and case management. Any additional fees incurred will be discussed with the client, as soon as possible, if they become relevant.
  • Charges for services not covered by payer(s) will be billed to the client.
  • CFD will submit claims to appropriate payers for services provided. By signing this form, the client authorizes such billing and payment directly to CFD. The client further authorizes CFD to provide necessary information to the payer to complete this billing process.
  • The client will inform CFD of any changes in coverage as soon as possible. If the client is covered by a payer for which coverage ends for any reason, the client may be responsible for the full cost of treatment.
  • Clients in the program will receive a monthly statement listing services, payments and adjustments for the previous month. The statement will specify an amount due, if applicable. Fees are due on the 25th of each month.
  • Failure to keep the account current within two months may result in suspension from the program. If suspended, the client must ensure that the account balance is paid in full ($0 balance) for the client to be reinstated into the program. In this event, the client will be reinstated 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 for amounts owed by the client.

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:

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: 28a575597503b2f4bceb7a10eac818c7432e76c0
Timestamp Audit
December 29, 2020 8:04 pm PDTSOAR Program Fee Agreement Uploaded by Jason Dooley - jdooley@c-f-d.org IP 65.157.96.202
December 30, 2020 8:09 am PDTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
January 14, 2021 3:25 pm PDTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
March 18, 2021 2:56 pm PDT Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:56:39 - 65.157.96.202
March 18, 2021 2:56 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202