Client Information Sheet

Client Information Sheet
NOTE: Any and all information concerning medical background given to New Horizons Personal Management SFO LLC (NHPM) shall be held in the strictest confidentiality, stored off-site in a safety deposit box, and will not be released by the NHPM Life Coach, Spiritual Director, Facilitator and/or Limited Financial Consultant, its employees or agents, without prior written approval of the directee/client or unless ordered by a court of law. However, NHPM may divulge directee/client information to other health care providers or therapists if deemed in the best interests of the directee/client.
Last Name*
First Name*
Middle Initial
Mailing Address*
City*
State*
Zip*
Street Address
City
State
Zip
Cell Phone*
Home Phone
Work Phone
SingleMarriedDivorcedSeparatedOther
Referred By (Name and Address)
Employer*
Employer Address
Birthdate*

MonthDayYear
Date
SS # (Optional)
Spouse/Partner/Significant Other Name
Spouse Birthdate

MonthDayYear
Date
Children
Name
Birthdate

MonthDayYear
Date
Name
Birthdate

MonthDayYear
Date
Name
Birthdate

MonthDayYear
Date
Name
Birthdate

MonthDayYear
Date
Name of person to contact in case of Emergency*
Address
Cell Phone*
Home Phone
Work Phone
Under $10,000$10,000-$30,000$30,001-$50,000Over $50,000
FEE SCHEDULE:
Client/Signatory Income

Under $10,000

$10,000 - $30,000

$30,001 - $50,000

Over $50,000
1 Hour

$45.00

$125.00

$155.00

$185.00
1.5 Hours

$75.00

$195.00

$240.00

$285.00
Finish seven (7) sessions successfully and receive a 65% refund on all moneys paid! Sliding scale offered.

CASH PAYMENT IS EXPECTED AT TIME OF SERVICE RENDERED, unless other arrangements are made. Bills not paid within thirty (30) days of the billing date are subject to a service charge of 1.75% per month. Arrangements may be made to make monthly payments on any outstanding bills without incurring a service charge.

PLEASE NOTE: If your statement shows a balance due of over sixty days, and payments or arrangements for payments have not been made, your account may be submitted to a collection agency for collection. Any attorney fees, collection costs and court costs will be added to the directee/client’s outstanding balance.

PLEASE NOTE: If the directee/client fails to give notice of cancellation of an appointment without at least forty-eight hours notice prior to the appointment, the directee/client will be charged 50% of that client’s hourly rate for the canceled appointment.

By checking the box below, the directee/client accepts, acknowledges and understands that any costs incurred by New Horizons Personal Management SFO LLC in obtaining payment for services rendered will be paid by the directee/client. Such will be added to the final bill at the time of collection.
true
Date*

MonthDayYear
Date
Should be Empty: