Willow Ann Rose LPC CHT ~ SpiritWell
PO Box 42114 – Eugene, Oregon 97404
www.spirit-well.com
Phone: (541) 461-5424
For Secure Communication:
My Phone Does Not Save Client Contact Info
Nor Accept / Send Texts.
Leave Voicemail to Ensure a Return Call
Email: [email protected]
Emails May Reach Me More Quickly Than Phone Calls
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FINANCIAL AGREEMENT
By agreeing to enter into therapeutic work with Willow Ann Rose LPC CHT, we have begun a professional relationship that includes your agreement to certain financial obligations. In an effort to reduce any misunderstandings or difficulties in our work together, I welcome at any time your questions and comments regarding my financial policies.
Honoring the “No Surprises Act”
You have a right to receive a Good Faith Estimate of what your services may cost.
I Do Not Accept Insurance.
All Fees Are Private Pay.
“If you have insurance…”
I can provide you with a “superbill” (basically a simple medical receipt for Counseling services). You may be able to receive partial reimbursement for therapy by your insurance company if you have out-of-network benefits and submit the “Super Bill” I provide to you directly to your insurance panel.
Before our first session:
Check with your Insurance Company to ask if you have these benefits.
“Super Bill” Requires Full Payment (not sliding scale)
And will only cover Counseling/Psychotherapy Services.
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FEES FOR SERVICES
All services are direct exchange paid on the day of our meeting.
I offer a number of modalities, each requiring various time frames to support the specific practice.
Fee options are noted below for each modality.
Each modality offers a sliding scale option.
Choose the modality you are beginning or currently engaged in.
I trust humans to know their own financial needs better than I.
Please choose the most helpful fee for you at this time.
Your mutually agreed fee will be noted in your Financial Agreement completed at our first session together.
Payment choices may be changed if needed. Please contact to discuss at any time.
FEES NOTED FOR EACH SERVICE
Psychotherapy Sessions
- “50 Minute” Psychotherapy Session: $70 - $130
- “90 Minute” Psychotherapy Session: $110 - $160
90-minute sessions are also suggested for meetings by agreement:
May incorporate a number of practices.
Transpersonal Guided Hypnotherapy
- 80 – 90 Minutes: $110 - $170
- Two Hour Extended Session (By Agreement to support specific needs/focus): $140 - $225
Spirit Path Medicines ~ “Shamanic Practices”
- 3 to 4 Hours of Healing Services extending over the phases of the Healing Journey: $275 - $375
“Blossoming from Within”
~Spiritual Midwifery ~ Mentoring ~ Coaching
- 90 Minute Session Suggested: $105 - $160
- 50 Minute Session if Preferred: $70 - $130
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PAYMENT INFORMATION FOR ALL CLIENTS
Cash or Check Preferred.
In My Office:
I can accept payment via cash or personal check (made out to “Willow Rose”).
Please ask if you need a simple receipt for your payment, and I will provide it on the day of our session.
A $30 charge will be added to any check that is returned or needs to be re-submitted due to insufficient funds.
If you prefer to pay via credit or debit card, use the "PAY NOW" option available on the website.
If you choose to use this form of payment, it is still expected that you will reimburse the same day as your appointment.
CANCELLATION POLICY
Cancellation 48 hours prior to a scheduled session is greatly appreciated! Cancellation notice must be made a minimum of 24 hours before a scheduled session to avoid being charged for the missed session.
(Some modalities have different cancellation policies, which will be discussed at the time of scheduling those appointments.)
I do not charge for late cancellation when due to the following reasons:
Illness, Emergencies, and Inclement Weather are exceptions to this missed session charge.
If you need to cancel a session:
A voicemail message may be left on my office phone at any time.
Phone: 541-461-5424
Reminder:
My office phone does not accept texts and requires a brief voicemail to receive a response.
Or email: [email protected]
Email will often reach me more quickly than a phone call.
THE FOLLOWING PERTAINS TO BOTH TELETHERAPY AND OFFICE SESSIONS
If you have not contacted me or arrived by 15 minutes past the start of our scheduled session time, I will assume you will not attend the session and will utilize the remainder of the hour at my discretion. Please know that I may not be available if you arrive later than 15 minutes past our scheduled start time.
As a courtesy to the next scheduled client, if you arrive late for your session, note that our session will still end at the scheduled completion time. Remember, our 50-minute session period includes business matters such as paying for your session and scheduling the next appointment.
If I need to cancel a session, I will make every effort to contact you as soon as possible. In order to assist me in reaching you, please ensure I always have your current phone and email information.
LATE CANCELLATION FEES
- For first missed session without minimum 24 hours notice: Charge is 50% of your chosen session fee.
- For the second missed session without 24 hours notice: Charge is 100% of your chosen session fee.
If you have no-showed or late-cancelled twice and have not reimbursed for the late cancellation fees, I will ask that you pay in advance prior to scheduling your next session.
Please ask to explore options to support reimbursement for our work together... I am happy to discuss other financial arrangements.
IF YOU HAVE QUESTIONS ABOUT THIS AGREEMENT
CONTACT WILLOW BEFORE COMPLETING AND SIGNING THIS DOCUMENT.
Revised 2020 C., Updated: January 2025:
Willow Ann Rose LPC CHT ~SpiritWell
