I prefer that you call me on my

phone

Calls will be discreet, but please note any restrictions

EMERGENCY CONTACT:

REFERRAL:

PATIENT AGREEMENT:

1. All sessions are by appointment only. Payment due at time of service. (Cash, check, or major credit cards accepted.)

2. CANCELLATION POLICY: There is a 24-hour cancellation policy for all appointments. A cancellation fee will be charged for a full session in the event that it is missed.

3. The clinicians shall charge the Center’s regular hourly fee for time spent on telephone consultations with schools, case-workers, child protection services, requested paperwork and other correspondence.

Date

Date

AUTHORIZATION TO RELEASE INFORMATION: I authorize this office to release any information necessary to expedite my insurance claims including documentation required by my managed care case-workers should my plan require it

Date

PLEASE MAKE SURE YOU DOUBLE CHECK YOUR INFORMATION. YOU CAN'T GO BACK ONCE YOU CLICK SUBMIT!