What should a self-pay therapy invoice include?

Your practice details; the invoice number, date, payment terms, due date and the client's account number; the client's name and billing address; each session with its date, service and fee; any other fees, such as a late cancellation; the total; any payments already received; and the amount due.

How do I show a sliding-scale fee?

Enter the fee you agreed with the client in the Fee column and keep the Fee basis line, such as "Sliding scale, as agreed at intake". The sample bills 90.00 a session on that basis.

How do I bill a late cancellation?

Put it in the Other fees table with its date and your fee, under the cancellation policy the client agreed to. The sample's terms bill 45.00 for a session canceled with less than 24 hours' notice.

How do I show payments the client already made?

Type the total paid on the "Less: payments received" line and list the dates in the billing notes. In the sample, 90.00 was paid at each of two sessions, so 315.00 less 180.00 leaves 135.00 due.

What should I leave off the invoice?

Anything beyond services and fees. Describe each service in general terms, such as "Individual session, 50 min", and keep session notes in the client's record, as the sample's last note says.

Which format should I download?

Use the PDF for a blank A4 form to fill in by hand. Use the Word or Excel file to type the invoice: both have the same layout with a sample you overwrite. The Excel file calculates the amounts, subtotals, total and amount due; you type in the payments received.

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Q: Can my client use this invoice with an insurer?

It's a self-pay invoice with no insurance fields. If a client wants to claim the sessions from an insurer or another payer, check with the payer what it needs, such as whether it accepts an invoice like this or wants a different form.

A free self-pay invoice for a counseling or therapy practice, with session dates at the agreed fee, placeholders for the client and service codes, other fees such as a late cancellation, and the payments already received, as a blank PDF form plus Word and Excel files filled with sample values

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Quick answer:This page has a free self-pay invoice for a counseling or therapy practice billing a client directly. A Sessions table lists each session by date, service, a bracketed code placeholder, quantity and fee, and an Other fees table holds charges such as a late cancellation. A Sessions block records the session dates, the payment type and the fee basis, such as a sliding scale agreed at intake. Payments the client has already made are taken off the total to give the amount due. The client and codes are placeholders, and the sliding scale and cancellation fee are sample terms. There's no sales tax line and no insurance fields. It comes as a blank print-and-fill A4 PDF and as Word and Excel files filled with sample values.

THERAPY INVOICE

Practice

Practice name:: Example Counseling Practice
Address:: 36 Example Calm Street, Suite 2, Sampletown
Phone / email:: [Phone or email]
Therapist:: [Therapist name]
License no.:: [License no., if required where you work]

Invoice details

Invoice no.:: TH-0611
Invoice date:: Nov 30, 2026
Payment terms:: Net 14
Due date:: Dec 14, 2026
Account no.:: [Client account no.]

Bill to (client)

Client name:: [Client name]
Address:: [Address]
Email:: [Email]

Sessions

Session dates:: Nov 3, Nov 10 and Nov 17, 2026
Payment type:: Self-pay
Fee basis:: Sliding scale, as agreed at intake

Sessions

Service: Individual session, 50 minAmount: 90.00
Date:
Nov 3
Code:
[Code]
Qty:
1
Fee:
90.00
Service: Individual session, 50 minAmount: 90.00
Date:
Nov 10
Code:
[Code]
Qty:
1
Fee:
90.00
Service: Individual session, 50 minAmount: 90.00
Date:
Nov 17
Code:
[Code]
Qty:
1
Fee:
90.00

Sessions: line items
Date	Service	Code	Qty	Fee	Amount
Nov 3	Individual session, 50 min	[Code]	1	90.00	90.00
Nov 10	Individual session, 50 min	[Code]	1	90.00	90.00
Nov 17	Individual session, 50 min	[Code]	1	90.00	90.00

Sessions subtotal270.00

Other fees

Service: Late cancellationAmount: 45.00
Date:
Nov 24
Code:
-
Qty:
1
Fee:
45.00

Other fees: line items
Date	Service	Code	Qty	Fee	Amount
Nov 24	Late cancellation	-	1	45.00	45.00

Other fees subtotal45.00

Subtotal: 315.00
Total: 315.00
Less: payments received: 180.00
Amount due: 135.00

How to pay

Accepted methods:: Card, bank transfer or check
Account name:: [Account name]
Bank details:: [Bank name, account and routing numbers]
Payment reference:: Invoice TH-0611

Billing notes

Sample terms: sessions are billed on a sliding scale; the fee of 90.00 a session was agreed at intake.
Sample terms: a session canceled with less than 24 hours' notice is billed at 45.00.
Payments received: 90.00 at each of the sessions on Nov 3 and Nov 10, 2026.
Service codes are shown as [Code] placeholders; enter your own codes if you use them.
This invoice lists services and fees only; session notes stay in the client's record at the practice.

Please quote the invoice number with your payment.

Therapy self-pay invoice: sample preview. Download it below.

Key Features

Everything you need in a professional invoice template.

Sessions table with date, service, code placeholder, quantity and fee

Other fees table for charges such as a late cancellation

Sessions block with the session dates, payment type and fee basis

Client name, address and email as placeholders

"Less: payments received" for payments the client already made

Billing notes with sample terms for a sliding scale and late cancellations

Excel formulas for every amount, the subtotals, the total and the amount due

Blank 1-page A4 PDF to print and fill in by hand

Download the invoice template

The PDF is a blank invoice to print and fill in by hand. The Word and Excel files contain the sample details shown in the preview, ready for you to replace with your own. In the Excel file, each line amount is a formula: "Qty" × "Fee". The section subtotals, subtotal, total and amount due are formulas too. The amount due is the total minus the payments received.

THERAPY INVOICE

Practice

Practice name:: Example Counseling Practice
Address:: 36 Example Calm Street, Suite 2, Sampletown
Phone / email:: [Phone or email]
Therapist:: [Therapist name]
License no.:: [License no., if required where you work]

Invoice details

Invoice no.:: TH-0611
Invoice date:: Nov 30, 2026
Payment terms:: Net 14
Due date:: Dec 14, 2026
Account no.:: [Client account no.]

Bill to (client)

Client name:: [Client name]
Address:: [Address]
Email:: [Email]

Sessions

Session dates:: Nov 3, Nov 10 and Nov 17, 2026
Payment type:: Self-pay
Fee basis:: Sliding scale, as agreed at intake

Sessions

Service: Individual session, 50 minAmount: 90.00
Date:
Nov 3
Code:
[Code]
Qty:
1
Fee:
90.00
Service: Individual session, 50 minAmount: 90.00
Date:
Nov 10
Code:
[Code]
Qty:
1
Fee:
90.00
Service: Individual session, 50 minAmount: 90.00
Date:
Nov 17
Code:
[Code]
Qty:
1
Fee:
90.00

Sessions: line items
Date	Service	Code	Qty	Fee	Amount
Nov 3	Individual session, 50 min	[Code]	1	90.00	90.00
Nov 10	Individual session, 50 min	[Code]	1	90.00	90.00
Nov 17	Individual session, 50 min	[Code]	1	90.00	90.00

Sessions subtotal270.00

Other fees

Service: Late cancellationAmount: 45.00
Date:
Nov 24
Code:
-
Qty:
1
Fee:
45.00

Other fees: line items
Date	Service	Code	Qty	Fee	Amount
Nov 24	Late cancellation	-	1	45.00	45.00

Other fees subtotal45.00

Subtotal: 315.00
Total: 315.00
Less: payments received: 180.00
Amount due: 135.00

How to pay

Accepted methods:: Card, bank transfer or check
Account name:: [Account name]
Bank details:: [Bank name, account and routing numbers]
Payment reference:: Invoice TH-0611

Billing notes

Sample terms: sessions are billed on a sliding scale; the fee of 90.00 a session was agreed at intake.
Sample terms: a session canceled with less than 24 hours' notice is billed at 45.00.
Payments received: 90.00 at each of the sessions on Nov 3 and Nov 10, 2026.
Service codes are shown as [Code] placeholders; enter your own codes if you use them.
This invoice lists services and fees only; session notes stay in the client's record at the practice.

Please quote the invoice number with your payment.

Therapy self-pay invoice

A self-pay invoice from a counseling practice: the client as a placeholder, session dates at a sliding-scale fee with bracketed code placeholders, a late cancellation fee as sample terms, the payments received and the amount due.

A request for payment — shows the amount due

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What this therapy invoice is for

Use this invoice when a client pays your practice directly for counseling or therapy sessions. It lists each session by date with its fee, any other fees such as a late cancellation, and what the client has already paid, so the amount due is clear.

Other self-pay invoices on this site are built for other practices:

the speech therapist invoice bills an evaluation fee and session fees, less the payments made at each session;
the acupuncturist invoice bills an initial visit and follow-up visits, less a prepaid package;
the chiropractor invoice bills services by visit date, less the payments made at each visit.

The invoice is titled THERAPY INVOICE and has these parts:

Practice: practice name, address, phone or email, the therapist, and a license number field reading "[License no., if required where you work]".
Invoice details: invoice number, invoice date, payment terms, due date and the client's account number.
Bill to (client): client name, address and email, all placeholders in the sample.
Sessions block: the session dates, the payment type ("Self-pay") and the fee basis ("Sliding scale, as agreed at intake").
Sessions: Date, Service, Code, Qty, Fee and Amount, with a "Sessions subtotal" and two blank rows.
Other fees: the same columns, with an "Other fees subtotal" and one blank row.
Totals: Subtotal, Total, "Less: payments received" and Amount due. There's no sales tax line.
How to pay and Billing notes.

How the sample adds up

The sample is invoice TH-0611, dated Nov 30, 2026:

Sessions: individual 50-minute sessions on Nov 3, Nov 10 and Nov 17, each at 90.00, for 270.00. The code column shows "[Code]".
Other fees: a late cancellation on Nov 24, 45.00.
Subtotal and total: 315.00.
Less: payments received: 180.00, the 90.00 paid at each of the sessions on Nov 3 and Nov 10.
Amount due: 135.00, for the Nov 17 session and the late cancellation. On Net 14 terms, it's due Dec 14, 2026.

These figures only show how the form works; they aren't typical fees.

Sliding scale, cancellations and service codes

The billing notes hold the practice's terms, labeled as samples:

"Sample terms: sessions are billed on a sliding scale; the fee of 90.00 a session was agreed at intake."
"Sample terms: a session canceled with less than 24 hours' notice is billed at 45.00."

Replace them with your own fee and cancellation policy, as agreed with the client. If you use a sliding scale, enter the fee you agreed for that client in the Fee column and keep the Fee basis line, so the client sees the basis for the fee.

The Code column holds "[Code]" placeholders. The notes say "Service codes are shown as [Code] placeholders; enter your own codes if you use them." If you don't use codes, leave the column empty.

Keeping the invoice to services and fees

An invoice may be seen by other people, such as whoever handles the client's mail or bills. The sample's last note says "This invoice lists services and fees only; session notes stay in the client's record at the practice." In practice:

describe services in general terms, such as "Individual session, 50 min";
send the invoice to the address or email the client gave you for billing, in the way the client agreed;
keep anything beyond services and fees out of the invoice.

Insurance, other payers and your license number

This is a self-pay invoice, with no insurance fields. If a client wants to claim the sessions from an insurer or another payer, check with the payer what it needs, such as whether it accepts an invoice like this or wants a different form.

For whether you must show a license number on invoices, check with your licensing board. The field can be filled in or cleared.

Filling in the template

The PDF is a blank form to print and fill in by hand. It's sized for A4 paper, so if you print on US Letter, check the scaling setting in your print dialog so the whole page fits. The Word and Excel files have the same layout filled with the sample, for you to overwrite.

In the Excel file:

each line's Amount is Qty × Fee, rounded to the cent;
the Sessions and Other fees subtotals, the Subtotal and the Total are formulas;
"Less: payments received" is an amount you type in, and Amount due is the Total less that amount;
the file's tip says: to leave out "Less: payments received", set it to 0.00, and don't delete these rows, because the totals refer to them.

In Word or on the PDF, work out the amounts yourself.

Invoice templates by format: PDF, Excel, Word, Google Docs and Google Sheets, or browse all invoice templates. Other invoice templates: home health care.

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What's included in this invoice template

	This invoice	Speech therapy	Acupuncture	Chiropractic
Lines	Sessions, other fees	Evaluation and session fees	Initial and follow-up visits	Services by visit date
Taken off	Payments received	Payment at session	Package credit	Payment at visit

When this isn't for you

If you bill an insurer or another payer directly, check with the payer what form it needs; this invoice is for clients who pay you themselves. If your practice management software already issues invoices, use it so your appointments and invoices match.