SOCIAL MEDIA

Client Forms

REFERRAL FORM

If you would like to make a referral, please complete our referral form. Email​ it to [email protected] or Fax it to 888-972-4998.  You may also Make a Referral Online. 

Referral Form
File Size: 61 kb
File Type: doc
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NEW CLIENT REGISTRATION FORM

​If you are a new client, please Contact Us using the Form.  

You may also Print out the Consents below following Client Registration and Consents.  You may either bring them or send them to us by fax or email prior to your first appointment.  Additional items to bring include a valid id, insurance card, proof of guardianship for minors such as birth certificate and a list of medications if applicable.  You can send the forms confidentially by Fax @ 888-972-4998 or by Email to [email protected].  You may also complete the forms and upload documents through a Secure Internet Connection ONLINE.

    Contact us:

    Please complete the form below to send us a confidential request for information. 

    ​To expedite scheduling an appointment, please complete the New Client Registration.  

    W    e will reply asap within one business day.
Client Registration & Consents
File Size: 608 kb
File Type: pdf
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AUTHORIZATION TO RELEASE INFORMATION

All client health information discussed in sessions is Confidential as stated in the HIPAA-Privacy Policy and will only be released at the request of the client or legally responsible person.  If you are using insurance, we must have an Authorization to Release Information on file for Insurance Billing Purposes only.  You may also use this form if you would like us to have communications with a family member, family doctor or any other designated person, agency or facility.   Proof of client identity and signature may be requested. 
AUTHORIZATION TO RELEASE INFORMATION
File Size: 358 kb
File Type: pdf
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CREDIT CARD PAYMENT AUTHORIZATION & PAYMENT POLICY

Thank you for choosing us as your mental health provider. We are committed to providing you with quality and affordable care. Because some of our clients have had questions regarding client and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.
Credit Card Auth & Pmt Policy
File Size: 966 kb
File Type: pdf
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