Patient Payment Registration Form

Applicable Session Fees:

COPAY $ 15.00

COPAY $ 20.00

COPAY $ 25.00

COPAY $ 30.00

COPAY $ 50.00

SLIDING SCALE $ 80.00

DEDUCTIBLE $ 150.00

INITIAL INTAKE ASSESSMENT FEE

DEDUCTIBLE $ 125.00

FOLLOWUP THERAPY SESSION FEE

Total $ 0.00

E-mail
Sex
Date of Birth

Month Day Year
Contact Number:

Area Code Phone Number
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
In Case Of An Emergency...
Emergency Contact:

First Name Last Name
Relationship
Contact Number

Area Code Phone Number
Taking any new medications, or has there been any changes in medications?

Yes No
If yes, please list it here
Should be Empty:

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