Registration Forms

The Financial Form

The Insurance Form

CONSENT FOR SERVICES/TREATMENT AGREEMENT

I,                                               hereby agree that I or my child/ward have voluntarily authorized and give full permission to the Hellenic Therapy Center to provide service/treatment, diagnostic evaluations and/or other services including medical/psychiatric treatment to me       , my child/legal ward             , as deemed necessary and appropriate by Hellenic Therapy Center. I understand that services at the Center may be discontinued at anytime by either party. In the event that I decide to discontinue services/treatment I understand that the Center encourages that a discussion about discharge take place between me and the Staff Personnel assigned to me.

Date
CANCELLATION POLICY REQUEST

If I fail to cancel a scheduled appointment within 24 hours, I hereby authorize that my credit card (or debit card) below will be charged the full professional fee for the service. Cancellation notice requires 24-hour advance consent and acknowledgement of the cancellation by the clinician with whom I am scheduled, or the Director.

I,                                               am authorizing Hellenic Psychology Center to use my credit card (or debit card) information to charge it according to the terms in this Cancellation Policy Agreement that I have reviewed and signed.

Date

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