Colors of austin counseling

Reduced Rate Therapy Request Form

Your request for reduced rate therapy services is on the basis of an “honor system” relationship between you and Colors of Austin Counseling. It is expected that you notify us if your ability to pay more has changed. As you can make incremental increases in the number of your payments, other clients who also have specific financial circumstances may then be able to benefit from the reduced rate position you have made available. While we will do our best to accommodate all, specific requests for reduced fee services will be evaluated based on need and availability.

Regardless of your circumstances, you are entitled to the full benefits of services. In fact, your clinician will be unaware of your financial agreement, as they do not have access to billing information or billing arrangements. Regardless, Colors of Austin Counseling maintains a commitment to support equitable treatment and we encourage you to talk to us directly or email us at connect@colorsofaustincounseling.com if our practice seems to be out of alignment with our commitment.

Please note that by law, reduced fees may not be combined with insurance payments or applied to a co-pay, co-insurance, deductible, or out-of-pocket calculation. To seek direct reimbursement through a health insurance policy, you must pay the full fee per session at the time of service.

To request services, please complete the form below in its’ entirety. Our Client Care Coordinator will connect with you within 1-2 business days to discuss next steps.

Name

First Name

Last Name

Email Address

Phone Number

(###)

###

####

Preferred Language

Date of Birth

What is bringing you in to therapy?

Therapist you'd like to see

Martha Horta Granados

Jasmeen Wilson

Not sure, help me choose!

Are you interested in virtual* or in-person therapy?

*Please note, client must be a resident of Texas to receive therapy services.

Virtual / Telehealth

In-person / East Austin Office

Type of therapy you are interested in:

Individual therapy

Couples therapy

Family therapy

Other

Reduced rate therapy fees for a 50-55 minute session typically start at $80. Are you currently able to pay that fee? If not, what are you able to pay? Please note that we would expect a weekly commitment.

Please answer Yes, or provide an alternative rate that works for your financial situation.

Is there anything else that is important for us to know?

Let us know any presenting issues, concerns or areas to work on so that we can schedule you with a therapist that is the right fit for you!