Bend Psychological Services
Michael Conner, Psy.D
965 NE Wiest Way, No. 2
Bend, Oregon 97701
Phone (541) 388-5660   Fax (541) 388-4638

We Bill Most Insurances - as a courtesy to our patients

Services (Please Initial the services requested)

Required  Initial Treatment Appointment, Screening and Recommendations ($260)

______  Psychological & Counseling Services ($150 per hour, $50 per additional 30 minutes)

______  Consultation Services ($180 per hour, $90 per additional 30 minutes)

______  Educational Evaluation Services  ($180 per hour, $90 per additional 30 minutes)

______  Psychological & Behavioral Assessment Services ($180 per hour, $90 per additional 30 minutes)

______  Intervention, Educational & Placement Services ($180 per hour, non-treatment)

______  Intervention, Educational, Placement & Consultation Support Services Payable ($2800 flat fee per case, non-treatment. three months) Consultation Office Policy

______  Forensic & Support for Legal Services ($250 per hour)

 

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Printed Name of Client/Authorized person

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Signature                                                                             date