Billing information for Adults

Billing information for Adults

Provide your contact, billing, and referral details, then review and e-sign the Memo of Understanding.
Personal & Contact Information
Name
Full Name
Birthdate

MonthDayYear
Date
Gender
Home Phone
Format: (000) 000-0000.
May we identify SpringHaven, Inc. when calling your home phone?
Work Phone
Format: (000) 000-0000.
Ext
May we contact you at work?
Cell Phone
Format: (000) 000-0000.
Email
Email for SpringHaven use only.
I would like to receive SpringHaven updates
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Employer
Social Security #

Family, Provider & Referral Information
Spouse's Name
Spouse's Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse's Employer
Physician
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Who referred you?

Other
Other

Memo of Understanding & Signature
I give permission for SpringHaven, Inc. to contact the person listed above for emergency contact in the event my counselor is concerned for my wellbeing. I understand that the hourly rate for the requested services is $150 initial intake and $130 for each additional therapy session. I understand that regardless of my insurance status, I am ultimately responsible for the balance on my 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.
Date

MonthDayYear
Signature
Should be Empty: