Please complete the following forms and bring them to your first session.
Also, call the mental health provider listed on the back of your insurance card (or the Employee Assistance Plan your company subscribes to) and inform them you have scheduled.
Your Authorization #___________________________________
Number of Sessions Allowed :__________________________
Copay=___________________________________________
Also, call the mental health provider listed on the back of your insurance card (or the Employee Assistance Plan your company subscribes to) and inform them you have scheduled.
Your Authorization #___________________________________
Number of Sessions Allowed :__________________________
Copay=___________________________________________
Til soon, Thanks!
Celebrate. Cultivate. Care. Communicate.
 Authorization of Information Form |
Print, Fill in, Bring to Session |
| Registration: Client Information and Insurance Information Form | Print and Bring |
| Parent/ Child Information Form | Print and Bring |
| Limits of Confidentiality |
Please Print and Sign |
| Susan Bramlette, LMFT, Policy and Protocols |
Please Print, Sign, and Bring to First Session |
Note: To download Adobe Acrobat Reader for free, click here.