• Payment for Out of Office Request

  • Patient DOB*
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  • Person completing this form relationship to patient. (A guardian or patient needs to complete this form for it to be valid)*
  • Please understand that if you are requesting or seeking a court order for a licensed therapist or other licensed professional to testify, our testimony is limited to the therapy or services personally provided to the patient or patients involved.

    We do not testify regarding third-party documents, statements, allegations, or other information provided to the therapist by individuals outside the therapeutic relationship, except as may be required by law or necessary to explain the clinical services provided.

    Our therapists do not make recommendations regarding parenting plans, parenting time, custody arrangements, separation, or divorce. We do not provide recommendations for or against a parent, guardian, or other party, and we do not serve as mediators, custody evaluators, parenting coordinators, or experts appointed to determine family-law disputes.

    Any testimony provided will remain within the scope of the therapist’s professional role, direct clinical involvement, treatment provided, and applicable legal and ethical obligations.

    For any request or requirement for a Teri’s Health Services clinician to appear, testify, provide a deposition, or otherwise participate in a legal proceeding pursuant to a court order, subpoena, or other legal request, payment is required in advance before the clinician begins any time away from regularly scheduled clinical duties.

    The fee for clinician time is $110 per hour. Billable time may include preparation, document review, consultation, waiting time, testimony, deposition time, and other time required for participation in the legal matter.

    When travel is required, a minimum of two hours of travel time will be charged. If the actual travel time exceeds one hour each way, travel time will be billed based on the actual time required, rounded to hourly increments. For example, if travel requires 30 minutes each way, the minimum two-hour travel charge will apply. If travel requires approximately 90 minutes each way, four hours of travel time will be charged.

    For court appearances, a prepaid half-day fee of $440 will be charged for virtual appearances. If travel and an in-person appearance are required, a prepaid half-day fee of $660 will be charged.

    If the actual time required for the court appearance or legal proceeding is less than the prepaid amount, any applicable refund will be calculated and issued after the service has been completed. If the proceeding requires additional time beyond the prepaid amount, the additional time will be billed at the applicable hourly rate.

    Payment of these fees does not alter or expand the clinician’s professional role or scope of testimony. Clinicians will testify only within the limits of their direct clinical involvement, professional knowledge, applicable laws, ethical obligations, and the policies of Teri’s Health Services.

     

    You can do stripe below or zelle to: teri@terishealthservices.org 

  • My Products*

    prevnext( X )
            Virtual (half day)


            $440.00$440.00
              
            Virtual (full day)


            $880.00$880.00
              
            In person (half day)

            accounts for 1 hour or less drive for one way. If longer driving then 1 hour you will be charged a second fee. 

            $660.00$660.00
              
            In person (full day)

            accounts for 1 hour or less drive for one way. If longer driving then 1 hour you will be charged a second fee. 

            $1,100.00$1,100.00
              
            Total
            $0.00$0.00

            Debit or Credit Card
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