HEALTH AND SOCIAL INFORMATION

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Have you ever experienced any of the following?

OCCUPATIONAL INFORMATION

EDUCATIONAL INFORMATION

RELIGIOUS/SPIRITUAL INFORMATION

MARITAL INFORMATION

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FAMILY COMPOSITION

OTHER INFORMATION

Consent For Communication
No Show, Late Cancellation and Co-payment Policy
Credit / Debit Card Payment Consent Form
Health Insurance Claim Form

Primary Insurance Information:

**Please be advised that copayments/coinsurance payments and/or self-payments will be charged 24 hours before your appointment. Failure to remit payment will result in a service charge fee of $15.00.** *** A service charge of my full session fee with be applied for any scheduled appointment not cancelled within 24 hours (or rescheduled within the same business week), or for failure to attend a scheduled appointment.***
Person policy is under*
Person policy is under*
Person policy is under*

SECONDARY Insurance Plan (If not applicable, skip)

Person policy is under*
Person policy is under*
Person policy is under*
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 CHILD PSYCHOTHERAPY