Therapist Receipt Template
A therapist receipt confirms a payment after it arrives: who paid, how, for what and the balance left. This one records $1,035.00 paid by card for a first month of weekly individual therapy for a self-pay client, starting with an intake assessment and including one joint session with a partner across 7 lines, balance zero. Edit it and download the PDF.
Pre-filled for a therapist: a first month of weekly individual therapy for a self-pay client, starting with an intake assessment and including one joint session with a partner. Example prices: replace them with your own.
From
Granite Private Therapy
781 Market Street
Salem, MA 01970
billing@example.com
(512) 555-0181
Receipt
Received from
Dana Whitfield
14 Elm Street
Springfield, IL 62704
client@example.com
| Description | Qty | Rate | Amount |
|---|---|---|---|
| Intake assessment (CPT 90791)Initial diagnostic evaluation, 60 min | 1 session | $200.00 | $200.00 |
| Individual psychotherapy, 45 min (CPT 90834) | 3 session | $150.00 | $450.00 |
| Joint session with partner present (CPT 90847)50 min | 1 session | $170.00 | $170.00 |
| Late cancellation, under 24 hours' notice | 1 each | $75.00 | $75.00 |
| Between-session phone consultationBilled after the first 10 minutes | 2 15 min | $40.00 | $80.00 |
| Treatment summary letter to client's physician | 1 each | $60.00 | $60.00 |
| Superbill for out-of-network claim | 1 each | $0.00 | $0.00 |
- Subtotal
- $1,035.00
- Total paid
- $1,035.00
Notes
Paid in full for a first month of weekly individual therapy for a self-pay client, starting with an intake assessment and including one joint session with a partner. Thank you.
Paid
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Therapist receipt at a glance
| Amount received | $1,035.00 |
|---|---|
| Paid for | A first month of weekly individual therapy for a self-pay client, starting with an intake assessment and including one joint session with a partner |
| Payment method (sample) | Card |
| Balance after payment | $0.00 |
| Receipt number | RCT-8601 |
| Lines itemised | 7 |
Lines on the therapist receipt
| Paid for | Amount |
|---|---|
| Intake assessment (CPT 90791) × 1 session | $200.00 |
| Individual psychotherapy, 45 min (CPT 90834) × 3 session | $450.00 |
| Joint session with partner present (CPT 90847) × 1 session | $170.00 |
| Late cancellation, under 24 hours' notice × 1 each | $75.00 |
| Between-session phone consultation × 2 15 min | $80.00 |
| Treatment summary letter to client's physician × 1 each | $60.00 |
| Superbill for out-of-network claim × 1 each | $0.00 |
| Total paid | $1,035.00 |
| Balance due | $0.00 |
What a therapist receipt proves
A therapy receipt should list the date of service, session length and amount paid without any clinical detail, so the client can submit it to an HSA or FSA.
In the sample, Dana Whitfield paid $1,035.00 by card for a first month of weekly individual therapy for a self-pay client, starting with an intake assessment and including one joint session with a partner, so the receipt shows the full amount and a zero balance.
Recording how the customer paid
- Card: card type, last four digits and the $1,035.00 charged
- Bank transfer: the date the $1,035.00 cleared and the payer's reference
- Cash: the amount handed over and any change given
- Cheque: cheque number and bank, receipted once it clears
Avoiding therapist payment disputes
- Insurers generally do not reimburse late-cancellation fees, and clients are surprised to see them. Listing the fee on its own line, never coded as a session, and citing the policy signed at intake keeps it clean.
- Billing a 45-minute session under the 60-minute code, or the reverse, gets claims denied or recouped later; the minutes printed on each line should match your session notes.
Refunds and corrections
If part of the $1,035.00 is refunded, do not edit the old receipt: issue a credit note or a refund receipt that points to RCT-8601 and states the amount returned.
Frequently asked questions
How do I make a therapist receipt?
Enter who paid, what for and how, list the lines (or one summary line), and mark the amount paid. The sample records $1,035.00 paid by card for a first month of weekly individual therapy for a self-pay client, starting with an intake assessment and including one joint session with a partner, leaving a zero balance.
What is the difference between a therapist invoice and a receipt?
The invoice asks for payment of the $1,035.00 and gives a due date; the receipt confirms the money arrived and shows how it was paid. Many customers need both for their records.
Can I give a receipt for a deposit?
Yes. Issue a receipt for the amount received now and a second one when the balance is paid, both referring to the same job.