Forms, Fees and Policies

​This page explains Samar’s current fees, payment and scheduling policies, client forms, privacy notices, and options for completing paperwork in an accessible way. The full informed-consent and practice-policy documents are provided through Samar’s secure client portal before services begin. Please ask about anything that is unclear or that you would like explained differently.

 

Fees

​

Individual psychotherapy
$255 per session

​

Family and relationship psychotherapy
$275 per session

​

Clinical consultation
$275 per session

​

Group psychotherapy
Fees vary by group. The cost, schedule, format, and attendance expectations for a specific group will be provided before enrollment.

​

Fees may be changed with advance written notice. Any change will apply prospectively and will not affect services already provided.

​

Insurance and Superbills

Samar Neurodivergent Therapy Center is a private-pay practice and is not in network with any insurance plan. Payment is made directly to Samar.

​

Upon request, Samar can provide a superbill that you may submit to your insurance company for possible out-of-network reimbursement. A superbill generally includes identifying information, dates of service, service codes, fees, and a mental health diagnosis.

​

Reimbursement is determined by your insurance plan and is not guaranteed. Clients are responsible for confirming:

• Whether their plan includes out-of-network mental health benefits

• Whether a deductible must be met

• What percentage of the fee may be reimbursed

• Whether prior authorization is required

• How submitting a diagnosis may affect the claim

 

Samar will not change a diagnosis, service code, date of service, or clinical record solely to obtain reimbursement.

​

Payment

Payment is due at the time of service unless another arrangement has been approved in writing.

A valid payment method may be required to remain on file through Samar’s secure payment processor. Full payment-card information should not be sent through email, text message, or the website contact form.

When someone other than the client pays for therapy, that person does not automatically become the client and does not automatically receive access to clinical information. Any release of information must be separately authorized when required.

​

If a payment is declined or a balance remains unpaid, Samar will contact the financially responsible person to resolve it. Additional appointments may be paused after reasonable notice while an outstanding balance is addressed.

​

Cancellation and Rescheduling

Appointments cancelled or rescheduled with less than 48 hours’ notice are charged the full scheduled fee. Weekends and holidays count toward the 48-hour period.

​

When another appointment is available within the same calendar week, Samar may waive the cancellation fee and move the session. A same-week appointment is not guaranteed, and the fee waiver is determined individually.

​

No fee is charged when Samar cancels an appointment. A fee may also be waived in the case of an unusual emergency or other compelling circumstance. A waiver in one situation does not change the policy for future appointments.

​

Late Arrivals

Sessions end at the originally scheduled time, including when a client arrives late.

When a client arrives more than 15 minutes late and there is not enough remaining time to conduct a clinically appropriate session, the appointment may be treated as a missed session and charged under the cancellation policy.

​

Recurring Appointment Times

A recurring appointment time is reserved based on clinical need and availability.

​

Repeated cancellations, missed appointments, or ongoing scheduling conflicts may lead to a discussion about changing the appointment time, reducing frequency, scheduling based on current availability, or ending the recurring reservation.

​

The goal is not to penalize disability-related needs or changing circumstances. It is to determine whether the reserved time continues to work for the client and the practice.

​

Client Forms

After an initial appointment is scheduled, clients receive the forms relevant to their care through Samar’s secure client portal.

​

Depending on the service and the people involved, forms may include:

• Client information and accessibility preferences

• Informed consent for psychotherapy

• Practice, payment, scheduling, and cancellation policies

• Telehealth consent

• Electronic communication preferences

• Notice of Privacy Practices

• Good Faith Estimate

• Authorization to exchange information

• Support-person participation permission

• Financially responsible party agreement

• Emergency-contact information

• Supported decision-making or legal-authority information

• Minor-client consent and custody information

• Group-specific agreements

 

Not every form applies to every client. Samar will send only the documents that are relevant to the service being provided and the client’s circumstances.

​

Accessible Forms and Communication

Forms do not have to be completed in only one way.

Clients may request to:

• Review forms verbally with the therapist

• Receive a plain-language explanation

• Complete forms using writing, typing, AAC, pictures, or another communication method

• Have questions presented one at a time

• Take additional time to process or respond

• Have key information summarized in writing

• Use a trusted support person when appropriate and authorized

• Request another reasonable communication or disability-related accommodation

 

A person may also request an accommodation later, even if it was not identified during intake.

To request an accessible format or support with paperwork, contact Samar before the appointment or tell the therapist at any point during care.

​

Good Faith Estimates

Clients who do not have health insurance, or who do not intend to use insurance to pay for Samar’s services, have the right to receive a written Good Faith Estimate of expected charges.

​

A Good Faith Estimate may be provided when services are scheduled or when an estimate is requested. It is an estimate rather than a bill, and actual frequency or duration of treatment may change based on clinical needs, client preferences, and other circumstances.

​

You may ask for a Good Faith Estimate or an updated estimate at any time.

​

Privacy and Confidentiality

Samar generally keeps psychotherapy information private. Information may be used or disclosed for treatment, payment, practice operations, safety responsibilities, or other circumstances permitted or required by law.

Naming an emergency contact, family member, support person, caregiver, or person who pays for services does not automatically authorize Samar to share clinical information with that person.

Please do not send detailed clinical, medical, safety, financial, or legal information through the general website contact form. The contact form and regular email are intended primarily for initial inquiries and administrative communication.

​

Clients will receive information about Samar’s privacy practices and their rights before or at the beginning of services.

​

Client Notices

The following documents are available for review:

[BUTTON: California Board of Behavioral Sciences Notice to Clients]

[BUTTON: Notice of Privacy Practices]

[BUTTON: Good Faith Estimate Rights]

Paper copies and accessible versions are available upon request.

 

Communication Between Sessions

Brief scheduling and administrative messages are not ordinarily billed.

​

Email, text messages, voicemail, and portal messages are not monitored continuously and should not be used for urgent or emergency needs. Sensitive clinical matters may need to be discussed during a session or through another secure method.

​

Longer clinical calls, extensive written communication, forms, meetings, or care coordination outside scheduled sessions may involve an additional fee. Any applicable fee will be discussed before the service whenever reasonably possible.

​

Emergencies

Samar is an outpatient psychotherapy practice and does not provide continuous monitoring, 24-hour crisis response, or emergency services.

For an immediate medical or safety emergency, call 911 or go to the nearest emergency department. Do not rely on email, voicemail, text messaging, the client portal, or the website contact form for an emergency.

 

Questions About Fees, Forms, or Policies

Questions are welcome. Clients may ask for clarification, request that information be explained in another way, or discuss an accommodation before signing a document.

​

​