Family Intake Form- SP

How did you hear about us?

Other Information

Consent For Communication
No Show, Late Cancellation and Co-payment Policy
Health Insurance Claim Form

Self Pay Agreement:

Please Initial
Patient’s or Authorized Person’s Signature: I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment claims related to medial services provided.

INFORMED CONSENT TO INDIVIDUAL & FAMILY PSYCHOTHERAPY

Please Initial