Name_______________________________

Address_________________________________________________________________

Telephone numbers_____________________

E-mail address_________________________

Please list your customary fees for each of the following activities. If you usually make any other special arrangements with your clients (e.g. minimum number of hours) please note them in the margins. Please remember, this information will be considered confidential and used only by PsyBar to help us estimate our own costs in advance of subcontracting your services.

_________ Records review

_________ Psychological evaluation

_________ Report preparation

_________ General legal consultation

_________ Testimony

_________ Full day of testimony

_________ Travel

_________ Other

Tax ID/ Social Security number _______________________