Billing Information for Minors

Billing Information for Minors

Complete your child’s billing and contact details, custody information, and agree to the memo before signing electronically.
Child's Name
Full Name
Birthdate

MonthDayYear
Gender
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email
Email for SpringHaven use only.
I would like to receive SpringHaven updates
Mother/Guardian
Mother/Guardian Name
Full Name
Employer
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
May we contact you at work?
Father/Guardian
Father/Guardian Name
Full Name
Employer
Work Phone
Format: (000) 000-0000.
May we contact you at work?
Custody
Note: If the above child has a legal guardian or special custody arrangements, please complete the following.
Do you have:
Guardian/Custodial Parent Name(s)
Full Name
Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Guardian Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Other Information
Doctor's Name
Who referred you?

Other
Other referral source
Emergency Contact
Emergency Contact Phone #
Format: (000) 000-0000.
Memo of Understanding
I understand that the hourly rate for the requested services is $150 for the initial visit and $130 per therapy session thereafter. I understand that regardless of my insurance status, I am ultimately responsible for the balance on this account for any professional services received and that payment is due at the time of service. I have read the Financial and Cancellation policies in the Client Guide and agree to these conditions. I certify this information is true and correct to the best of my knowledge and will notify you of any changes.
Signature
Date

MonthDayYear
Should be Empty:

Billing Information for Minors

Mother/Guardian

Father/Guardian

Custody

Other Information

Memo of Understanding