New Client Information / Financial Agreement
Client Name: ___________________________________Date of Birth: ____________________
Phone: (Please indicate primary confidential number by *) Home: _______________________
Mobile: ___________________Work: _____________________
Reason for seeking psychotherapy: ________________________________________________
Emergency contact: Name: ________________________ Phone: ________________________
Address: _______________________________________ Relationship: ___________________
Primary care physician, Name of Practice, Telephone number: ____________________________________________________________________________
Name of psychiatric prescriber/ body worker/ and or holistic practitioner, Telephone number: _____________________________________________________________________________
Name of person responsible for payment, If not self: __________________________________
Address: _____________________________________________________________________ Phone:______________________ D.O.B:_____________ Relationship: ___________________
Please note and sign below: Client agrees to all policies regarding fees and collection of unpaid balance as described. (See website for full description of policies.) Appointments cancelled with less than 48-hour notice will be charged in full.
Signature of Patient and/or Financial Representative Date
CONSENT FOR RELEASE OR EXCHANGE OF CONFIDENTIAL INFORMATION
Client Name: ________________________________________ Date of Birth: ______________
I hereby authorize the release and exchange of information between my psychotherapist, Rafael Perez, LCSW-R, and the following individual, agency, or institution:
Phone: __________________________________ Fax: _________________________________
Relationship to client: ___________________________________________________________
This authority extends to furnishings of copies by fax or mail of any desired portion of records, pertaining to the above-named client. This exchange is for the purpose of: ______________________________________________________________ and expires 1 year from the date signed unless otherwise specified.
The parties named above are hereby released from all legal liability that may arise from this exchange or release of information. I understand that I may revoke this consent at any time by informing all of the above parties in writing. A photocopy or electronic copy is as valid as the original. This is a strictly confidential client medical record. Redisclosure or transfer is expressly prohibited by law.
Client Signature: ______________________________________ Date: ____________________
Witness: ___________________________________________ Date: ____________________