• Provider Transfer

    Provider Transfer

    THE FAMILY GUIDANCE AND THERAPY CENTER
  • am switching providers and will begin receiving services from

  • at The Family Guidance and Therapy Center of California. I understand and agree that the same policies and procedures that I previously agreed to remain in effect under this new provider. This includes but is not limited to:

    • Privacy Practices Policy
    • Informed Consent
    • Payment agreement
    • Insurance billing
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • If you would like copies of any previously completed/sign paperwork under a previous provider, please request from your current provider.

  • Should be Empty: