Ingrid Oliansky, Licensed Marriage and Family Therapist
​MFC# 48975
Call for an appointment (818) 927-3855
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Financial Agreement
If you are using Insurance
If you have not paid down your deducible, you will be responsible for the full contracted rate.  As each plan has different rates, I will discuss this with you after I have checked your benefits with your insurance company before treatment commences.

All copayments are due on the date of service and can be paid in the following manner:

If we are meeting in person, I take all major credit cards using a Square Reader. I also accept checks and cash. If bringing cash, please try to bring exact change.

If our sessions are being conducted online, I will send you an invoice from Square, which you can pay online using a credit card. Alternatively, you can send me payment by Venmo (@Ingrid-Oliansky) or PayPal (IngridOlianskylmft@yahoo.com)
Private Pay Options
Individual Sessions are $100.00
Couples Sessions are $150.00

I do have sliding scale options starting at $60 per session. Please contact me to discuss

Payments can be made by credit card using a Square reader. If we are meeting online, I will provide you with an emailed invoice for payments.

You can also pay by Venmo (@Ingrid-Oliansky) or PayPal (IngridOlianskylmft@yahoo.com)
Name:
Date:
By signing, I am verifying that I understand and agree to the financial terms of this agreement.
Cancellation and Missed Appointments Policy
I require 24 hour notice of canceled appointments. Failure to do so will result in the client paying the fully contracted rate for that session regardless of whether their deductible has been paid or not.
Client Name: