Richard L. Azrin, Ph. D.
Cheryl Millsaps Azrin, Ph. D.
Leslie Kahn, LCSW
Amber Fox , LPC
4260 Cahaba Heights Court Suite 180
Birmingham AL, 35243
Voice: (205) 329-7815,
Fax: (205) 329-7816
Please complete as much as possible of these forms.
any items that don't apply
Be sure to
at the bottom of the form, in order for us to get your answers.
Please sign all of the following 3 forms:
Form 1) The first form asks for your contact and insurance information.
Form 2) The second form asks who we can obtain information from and release information to.
Form 3) The third form gives us permission to do telephone or video calls with you.