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

FEES per 50-60 minute session

SLIDING SCALE

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.

Name of Family Member                     Relationship                Gross Income

__________________________________            ___________________          ___________  pAnnual     pMonthly

__________________________________            ___________________          ___________  pAnnual     pMonthly

__________________________________            ___________________          ___________  pAnnual     pMonthly

__________________________________            ___________________          ___________  pAnnual     pMonthly

__________________________________            ___________________          ___________  pAnnual     pMonthly

 

Total number of family members  __   Total Income $____________  Your fee  $_______

                           

GROSS FAMILY INCOME                         NUMBER IN FAMILY

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

 

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.