I understand that I am responsible for my fee payment at the beginning of each appointment. I agree to be responsible for full payment of fees for services rendered regardless of whether insurance reimbursement will be sought. Leslie Rouder, LCSW will honor contractual agreements made with those managed health care companies which stimulate specific reimbursement restrictions.
I hereby consent to treatment by Leslie Rouder, LCSW. Although the chances for obtaining my goals for therapy will best be met by adhering to therapeutic suggestions, I understand that I have the right to discontinue or refuse treatment at any time. I understand that I am responsible, however, for any balance due prior to a decision to stop.
I hereby authorize the release of necessary medical information for insurance reimbursement purposes.
By signing below I consent that all information provided in this intake form has been answered to the best of my ability. This is a strictly confidential medical record. Redisclosure or transfer is expressly prohibited by law.