Payment is due at time of service unless other arrangements are made
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.
If you have not already done so, please schedule your first appointment through our secretarial staff at 801-525-4645.