Application for Flexible Fee Services for Empathy Consulting, Psychotherapy, or Training – click here to download full application. TherapyApplicationforFlexibleFeeServicesforPsychotherapy
Please read the following which is also included in the application:
In consideration for flexible fee services, I agree voluntarily agree to provide the following information about my life and finances. I agree to provide verification of such information if such verification is requested and to the extent that I am able to do so. I understand that any change in services or reduction in fee is voluntary, subject to change without notice, and may be conditional on the accuracy and verification of the information provided by me.
I understand that if my financial condition materially improves or deteriorates, then I may incur an additional reduction or increase in fees. I also understand and acknowledge: No one is obligated to reduce my fee nor am I obligated to accept any such agreement. I understand that such information will be regarded as confidential.
Please call me with questions LAgosta@UChicago.edu / 773-203-0269
(c) Lou Agosta, PhD, Alleingang, Inc Empathy Consulting Services