Name of Patient *
Name of Patient
Parent or Guardian of patient (only if patient is under 18)
Parent or Guardian of patient (only if patient is under 18)
Other Parent or Guardian of patient (only if patient is under 18)
Other Parent or Guardian of patient (only if patient is under 18)
Address *
Address
Cell Phone
Cell Phone
Home Phone *
Home Phone
Payment is due at time of service unless other arrangements are made
Name of Primary Insured (if different than patient)
Name of Primary Insured (if different than patient)
Conditions and Terms of Therapy *
Please click on each to show understanding
If desired, type a few words about what is bringing you into psychotherapy. This can be as general or as specific as you wish it to be, and will be shared with your therapist.
Authorization for Release of Confidential Information
Please check the following ot demonstrate understanding. Then provide the name and contact information of whichever individuals, agencies, or Insurance Companies that you authorize your Therapist to communicate with.
Please include your insurance company and others involved in payment, as we need your permission to submit billing information.
Electronic Signature *
Electronic Signature
I understand that typing my name in this field and clicking "Submit" I am allowing this field to represent my signature. This field must be filled out by the identified patient, or that patient's legal guardian if patient is under 18 years of age. I understand that if I am not that person than filling out this field and clicking "submit" represents fraud.