†††††††††††††††††††††††††††††††††††††††††††††

STEVE FRANKLIN, M.S.W., L.C.S.W.

6829 Gravois Ave.††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† 314-517-8383

St. Louis, MO63116†††††††††††† ††††††††††††††††††††††††††††††††† ††††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 familyís 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.

Clientís Signature___________________________†††††††††† ††††††††††††††††††† Date _________________

 

I authorize payment of medical benefits to Steve Franklin for psychotherapy services provided by him to me.

Clientís 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.