Hope Counseling Session Form

Client Name:

Email:

Phone:

Address:

Name of person completing form (if other than client):

What time of the day works better for you when setting an appointment?

Morning Session

Afternoon Session

Evening Session

Counseling Session:

Initial Session: 1 hour

Follow-Up Session: 50 minutes

Initial Consultation: 15 minutes

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The following information is to assist us with how we may best make financial adjustments in determining your fee. All information will be kept confidential. Please provide an estimate dollar amount to all the fields below:

Family Income:

Family Expenses:

Gross Annual Wages:

Charitable Donations:

House Payment/Rent:

Spouse Contributions:

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Monthly Expenses:

Car Payment:

Gas Bill:

Child Support (Total):

Insurance (Car, House, Life):

Total of Utilities:

Food:

Clothing:

Savings:

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Committed Monthly Payments

Number of Dependents:

Number of Children in College:

Credit Cards:

Loans:

Other Expenses:

Total Household Expenses:

How much do you think you can afford to pay per counseling visit?

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• Initial Session: 1 Hour - $120.00

• Follow-Up Session: 50 minutes - $100.00

• Initial Consultation: 15 minutes - $45.00

Fee adjustments are reviewed every 90 days (about 3 months), but please let us know any time your financial situation changes significantly, so that we can reconsider your status and adjust the fee appropriately.

Please know that Hope Biblical Counseling can only intake a percentage of ‘special circumstance’ clients. When you are financially able to pay full fees please do so because it opens spots for those who are not able to pay full fees.

Schedule An Appointment:

Let's talk!

(214) 632-0483

Hope Counseling Session Form

Schedule An Appointment:

750 West Main StreetLancaster, TX 75146

750 West Main Street
Lancaster, TX 75146