IFHP Copayment Acknowledgment and Payment Preference Form

As of May 1, changes to the Interim Federal Health Program (IFHP) require clients to contribute a portion of the cost of psychotherapy services. Under this new regulation, IFHP will cover 70% of the session fees, and clients are responsible for the remaining 30% as a copayment, which amounts to $61.50 per session.

This form is intended to help us understand your financial situation and determine a payment arrangement that is manageable and respectful of your circumstances. Your responses will not affect your access to care, and we are committed to working with you to ensure continued support.

Important: If you are unable to pay the 30% copayment and select an option indicating financial hardship, the unpaid portion will be fully absorbed by the clinic. This means:

You will not be charged later for the absorbed amount
You will not accumulate debt
Your care and access to services will not be affected

Please do not worry about your ability to pay, your well-being is our priority.

Please review the options below and select the one that best reflects your current situation:

First name

Last name

Phone

I understand the IFHP copayment policy and agree to pay 30% of my psychotherapy session fees, which amounts to $61.50 per session.

I understand the IFHP copayment policy and agree to pay 30% of my psychotherapy session fees. I would like to arrange a payment plan and make instalment payments as follows:

Amount per month: $________

Due to financial limitations, I am unable to pay the full 30% copayment. I can contribute the following amount per session:

Amount per session: $________

I am currently unable to contribute financially toward my psychotherapy sessions due to significant financial hardship.

Additional Comments (optional):

Client Acknowledgment

I confirm that I have read and understood the information above and have selected the option that best reflects my current financial situation.

Signature

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IFHP Copayment Acknowledgment and Payment Preference Form

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