top of page
ABOUT US
SERVICES
PAYMENT
JOIN THE TEAM
FORMS
CLIENT INFORMATION
CLIENT RIGHTS
CONSENT IN-PERSON SERVICES
CONSENT TO TREATMENT
FINANCIAL POLICY
PAYMENT CONTRACT
RELEASE OF INFORMATION
TELEHEALTH CONSENT
REFERRAL FOR MENTAL HEALTH SERVICES
CONTACT
Payment Contract for Service
Name(s)
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
arrow&v
Phone
Email
Bill to:
Person responsible for payment of account:
Person Responsible Street Address
Person Responsible Street Address Line 2
Person Responsible City
Person Responsible State
Person Responsible Zip Code
Person Responsible Country
Country
arrow&v
Phone
Email
CONTINUE
bottom of page
