Autism Scholarship/JPSN Policy Form | Center for LifeSkills

Fee Schedule/Consent Form JPSN Scholarship/Autism Scholarship

Effective August 2015 – applicable to Stefanie J. Peck, M.A. CCC-SLP and The Center for LifeSkills

OFFICE VISITS - Occupational/Speech Therapy		SCHOOL VISITS - - Occupational/Speech Therapy
Initial Session	$375.00	Initial Session -	$375.00
Weekly Session – 30 minutes	$68.25	Weekly Session – 30 minutes	$94.50
Weekly Session – 45 minutes	$89.25	Weekly Session – 45 minutes	$115.50
Weekly Session – 60 minutes	$105.00	Weekly Session – 60 minutes	$131.25
Consultation	$105/hr	Consultation	$105/hr

OTHER FEES *these fees may not be billable to ODE
School Meetings - $105.00/hour
IEP design - $200.00
Training/Inservice - $142.00/hour

PAYMENT
Services will be billed monthly. The ODE check will be received by our office and families thereafter. Checks should be endorsed and returned immediately after they are received. Families will be expected to sign the Check Deposit Consent Form if the clients attend therapy outside of our facility. For families who attend therapy at our facility, we expect the checks to be signed in our office. We reserve the right to suspend therapy services if the check is not signed within 14 days. Assessments, meeting attendance, and other administrative tasks are not included under the scholarship. The scholarship can only be used for direct speech services to the student. I will sign all scholarship checks received by my providers for my student in a timely manner. I understand that if I fail to endorse the scholarship checks to the provider within 30 days, I will be responsible for paying my student’s fees.
Initial Here*
I understand that I am responsible for keeping track of funds available for therapy. Any overages that are not paid by ODE will be billed directly to me.
Initial Here*
I have read and understand this Fee Schedule/Consent Form and agree to its terms.
Parent’s Name*
Parent’s Signature*
Child’s Name*
Child’s Date of Birth*