No show/cancellation policy: 

Consistency is an important part of your or your child's therapy. We also hold appointment times for you and your family that we cannot offer to other families if an appointment is canceled at the last minute. For no shows or cancellations made less than 24 hours in advance, a late cancel/no-show fee of $50 will be charged to your card on file. We may choose to waive the fee at our discretion. 

Because we understand that sometimes people make mistakes or circumstances are beyond your control, our general guideline is to waive the fee for the first no-show/cancellation and for unforeseen or emergency circumstances such as sudden illness and dangerous road conditions. Please note that if frequent cancellations and no-shows are interfering with treatment, your therapist may need to terminate treatment or no longer guarantee a certain time slot in order to offer this time to another client. 

Clients using Medicaid insurance are exempt from the late cancel/no show fee, but your therapist may not be able to guarantee a regular time slot for treatment in the case of recurring no shows or cancellations. 

Insurance Policy: 

By entering your insurance information, you are giving us permission to bill your insurance and to communicate the personal information with your insurance company necessary for billing purposes. Please note that we must provide a mental health diagnosis in order to bill insurance. Please discuss this with your or your child's therapist if you have concerns about this diagnosis. We believe that, while a diagnosis may be necessary, it is merely a description of symptoms and does not define you or your child.  

Please be advised if you are using insurance coverage, this is a contract between you and your insurance company, not Family Roots Therapy.

We will verify your insurance availability at the time of service, but we are unable to give you an estimate for cost. You are ultimately responsible for understanding your insurance benefits and you will be responsible for any fees not covered by insurance. If you are concerned about coverage, we encourage you to contact your insurance company directly to confirm coverage. 

You are also responsible for keeping your insurance information updated and notifying us of any changes in coverage. 

Please choose the "self pay" option if you are paying out of pocket for services. If you require a superbill to be reimbursed by your insurance company, please let us know by contacting info@familyrootstherapy or 503-746-3373 and we will provide instructions for how to download your superbills/receipts from the client portal. 

Credit Card on file: 

We require that all clients save a credit card on file. You will be prompted to enter credit card information when filling out paperwork. Your credit card information is stored securely in our client portal. We cannot even see the credit card information once you enter it. 

By accepting this policy, you are consenting to charge any unpaid balances and cancellation fees as described in our policies to the card on file. 

Most clients prefer to have us bill the co-pay or session rate each week as a courtesy rather than log in to pay an invoice each week. If you prefer to pay each invoice on your own rather than be billed automatically, please let us know (info@familyrootstherapy.com) and we will not automatically bill your card each week. 

Please note that we do not allow clients to carry a balance (unless you have arranged for a payment plan) and your payment will be due each week at the time of session. Please note that if you choose not to be billed automatically, you may still be charged for overdue balances and cancellation fees. We will make attempts to reach out to you to arrange payment prior to making these charges. 

We do not accept cash or checks as forms of payment at this time. 

Because we are mindful of our clients' privacy, Family Roots offers secure messaging through our client portal. If you wish to communicate electronically about your treatment or your child's treatment, the client portal is the most secure method. 

Your therapist may use e-mail to communicate about scheduling needs but will not send sensitive or personal information via unencrypted e-mail. You may choose to use unencrypted e-mail to communicate with your therapist if you prefer, as we recognize that some clients prefer e-mail communication. (Certain employees at Family Roots Therapy have encrypted email capability through PauBox and are able to send sensitive information securely through email. Please contact info@familyrootstherapy.com for more details)

Please do not use text messages (SMS) to communicate with your therapist, as our phone system does not allow for texting on each therapists' individual extension. 

Family Roots uses Google Meet for Telehealth video sessions, which is a HIPAA secure video platform. You will receive links to join these sessions via e-mail. 

Therapists at Family Roots will not use any form of social media to communicate with clients and will not engage with clients on social media in any way, even if a client initiates contact. 

By signing below, I acknowledge that I have been informed of the risks of electronic communication and accept these risks should I choose to use unencrypted forms of communication.

For virtual (telehealth) sessions, Family Roots therapy requires the use of your camera during your sessions. Virtual sessions are required to be held in the state of Oregon as the licensure board does not allow for therapists to see clients who are located outside the state.

Family Roots Therapy providers who feel comfortable offering in-person sessions will follow all CDC and state guidelines for preventing the spread of illness. This includes physical distancing, wearing a mask, hand washing, and sanitizing. Guidelines will be shared with clients and providers will ask clients to adhere to all guidelines as well. 

Clients who cannot or will not adhere to guidelines for physical distancing and mask-wearing will be offered telehealth sessions rather than in-office sessions. 

Please do not attend an in-person session if you or someone in your household: 

-Has symptoms of COVID-19 (fever, chills, cough, shortness of breath, fatigue, headache, sudden loss of taste or smell)

-Has a fever of 100.4 degrees fahrenheit or higher

-Is undergoing evaluation for COVID-19 (such as a pending viral test)

-Received a diagnosis of COVID-19 (SARS-CoV-2) infection within the last ten days

-Has had close contact to someone with COVID-19 (SARS-CoV-2) infection within the last 14 days

If you are experiencing any signs of illness, please let your provider know as soon as possible and a telehealth session will be offered instead.

Notification of Fees:

Insurance:

Family Roots Therapy is contracted In-Network with various insurance companies and may be able to bill your insurance for part or all of your fees.  Clients using insurance out of network must pay the full prices listed above and are NOT eligible for sliding-scale. If we are in network with your insurance company, you are responsible for paying the patient responsibility according to your explanation of benefits (EOB) from your insurance, including co-pays, co-insurance or paying toward your deductible. You are ultimately responsible for knowing these details of your insurance coverage and for providing us with up to date insurance information. You must notify our office of any insurance changes or terminations. We may be able to provide an estimate of your costs as a courtesy, but please note that our estimate is an estimate only and not a guarantee of what your final bill will be. Please check with your insurance company directly to understand what services are covered. The explanation of benefits (EOB) that you receive from your insurance company will determine your patient responsibility. EOBs are typically processed and sent about 3-4 weeks after your session is billed. 

Please inquire about the following billing codes depending on your needs:

90791 - Mental Health Assessment (60 minutes)
90837 - Individual session (53+ minutes)
90834 - Individual Session (45 minutes)
90847 - Couples/Family Session (60 minutes)
90846 - Parent/Spouse support session w/o client present (60 minutes)

Payment of Fees:
Payment of fees you are responsible for is due upon the date of service.  Your counselor may choose to reschedule your appointment if you are unable to pay for the service. If you have a balance on your account, you will receive a statement. All accounts are due and payable within 14-days of notification. If you have questions regarding the payment of fees, please discuss them with our office manager or your counselor. Please discuss any concerns you may have regarding payment BEFORE it becomes delinquent.

If a client fails to be responsible for the account, and it is necessary to place a delinquent account into the hands of a collection agency/attorney, the client agrees to pay all court costs affixed by the court.

Your counselor accepts credit cards (Visa/MC, American Express, Health Accounts). These payments can be made on our client portal. 

Unpaid balances will be automatically charged to the card on file the day after your session if a copay or session fee was not paid at the time of service as outlined in our credit card agreement.

We are unable to accept checks and cash at this time. 

Our services are rendered at the full cost of $125/session for pre-licensed associates and $150/session for licensed providers when not using health insurance regardless of billing code.

If you are seen once per week, your estimated costs will be: 

$500/month (with 4 weeks of service) and $6500/year (with 52 weeks of service) if seeing a pre-licensed associate.
$600/month (with 4 weeks of service) and $7,800/year (with 52 weeks of service) if seeing a licensed provider.

If you are seen twice per week, your estimated costs will be:

$1000/month (with 4 weeks of service) and $13,000/year (with 52 weeks of service) if seeing a pre-licensed associate.
$1200/month (with 4 weeks of service) and $15,600/year (with 52 weeks of service) if seeing a licensed provider.

We offer a limited amount of sliding scale spots, so if the full rate is too great of a barrier, please reach out to our office staff to see what other options may be available.

Disclaimer:

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.

The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.

Please sign below to agree to the terms and acknowledge receipt of this Good Faith Estimate

The following forms and policies are available via our website (familyrootstherapy.com), in our waiting rooms or by requesting a copy from our front office info@familyrootstherapy.com:

Client Bill of Rights
Notice of HIPAA Privacy Practices
Declaration for Mental Health Treatment
Opportunity to Register to Vote
Grievance and Appeals Process

By signing below, you confirm that you have been given the access to read and understand these policies.