Jill K Harle Counseling
Clinical and Professional Therapy Services
Marriage & Couples
Jill Harle
Elizabeth Casey
Christopher Antczak
Jennifer Matthes
Alexis Ledner
Nicholas Mediate
Rebecca Kornberg
Amanda Keenan
Client Name (Required)
Type of Request (Required) ex. Treatment Plan, Confirmation of Treatment
Email Address of Recipient (if electronic copy required)
Address of Recipient (If physical copy required)
Due By 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Copy for Client Yes No
Any additional information necessary
Treatment plan: 50.00
Letters to confirm treatment: No charge
Correspondence with lawyers or attorneys: Fee charged at hourly rate
Patient file notes/copies: Charged for time and cost of copies.
Treatment/ Diagnostic summary: 100.00
There is a fee associated for most paperwork requests. Please sign an authorization to release if the special request includes further communication. Please feel free to ask for a quote prior to request.
Questions or comments? Get in touch:
127 S. 5th St.
jillkharle@gmail.com
Copyright © 2015 - 2019 Jill K Harle Counseling, LLC All rights reserved