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Rustemeyer Fee Agreement

Rustemeyer Fee Agreement


1215 Fern Ridge Parkway, Suite 110
St. Louis, Missouri 63141

Fee Agreement for
Georgean Rustemeyer, MSW, LCSW

Giving you the best possible service with consideration for your well-being is of utmost importance to us. The following is some information concerning fee schedules and payment procedures.

Individual session $145.00
(50 minutes)

Payment is due at completion of the session.

A Mastercard or Visa credit card account number and expiration date is required to guarantee payment. The credit card will not be charged as long as there is no balance on the account. If the balance has not been addressed, we will notify you that your credit card will be charged. Please fill in your credit card information on the Billing Information sheet.

Also, we offer Mastercard/Visa services to our clients. If you are interested in charging your visits to either your Mastercard or Visa Account, please fill in the space provided on the Billing Information sheet.

If the fees are covered by insurance, we will be happy to furnish you with an itemized statement for you to submit to your insurance company for reimbursement. If Medicare payments are not approved, client will be responsible for payment.

If an appointment must be cancelled for some reason, we require 24 hours notice. Appointments not cancelled 24 hours in advance will be charged to your account. If you need to cancel an appointment after 4:00 p.m. or on weekends, we do have an answering service available to take your calls. You can reach them by dialing our daytime number at 275-8599.

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