STEVE FRANKLIN, M.S.W., L.C.S.W.
6829 Gravois Ave.
314-517-8383
St. Louis, MO
63116 www.SteveFranklinMSW.com SteveFranklin@JUNO.com
This is my sliding fee scale, adjusted to make counseling more affordable for families with lower incomes. If you would like to pay the sliding fee, enter your family’s gross income (before deductions or expenses) below, and look at the chart below to determine your fee, based on income and number of persons in your family. Include child support, alimony, self employment, or any other income.
__________________________________ ___________________ ___________ pAnnual pMonthly
__________________________________ ___________________ ___________ pAnnual pMonthly
__________________________________ ___________________ ___________ pAnnual pMonthly
__________________________________ ___________________ ___________ pAnnual pMonthly
__________________________________ ___________________ ___________ pAnnual pMonthly
Total
number of family members __ Total Income $____________ Your
fee $_______
Annual Monthly 1 2 3 4 5+
<$15,000 <1250 FEE: $35 35 35 35 35
15,000 1250 40 35 35 35 35
18,000 1500 45 40 35 35 35
20,000 1666 50 45 40 35 35
25,000 2083 55 50 45 40 35
30,000 2500 60 55 50 45 40
35,000 2916 65 60 55 50 55
40,000 3333 70 65 60 55 50
42,000 3500 75 70 65 60 55
45,000 3750 80 75 70 65 60
50,000 4167 85 80 75 70 65
55,000 4583 85 85 80 75 70
60,000 5000 90 85 85 80 80
65,000+ 5417+ 90 90 90
90 90
Insurance
Company__________________Member # ________________ Auth. #
_______________________
Insurance
coverage and policy varies with each program.
Options may include:
pClient will pay full amount (and apply to insurance
directly for any reimbursement/deductible credit).
p Client will pay specified co-pay _____; therapist will apply directly to
insurance for remaining fee.
I authorize the release of
any medical or other information necessary to process insurance claims for
psychotherapy with Steve Franklin. I
also request payment of government or other insurance benefits either to myself
or on assignment to Steve Franklin.
Client’s
Signature___________________________ Date _________________
I authorize payment of
medical benefits to Steve Franklin for psychotherapy services provided by him
to me.
Client’s
Signature___________________________ Date _________________
Fees are due at the time of the session; client will
not be billed.
Client will be responsible for full amount if
insurance company does not acknowledge coverage or pay.