Online Therapy Form

Please complete and sign this online form.

View details of our agreement here and sign the digital agreement at the bottom of this form.

Therapy Form

  • CLIENT PERSONAL DATA RECORD

  • Emergency Contact Information

  • Financial Responsibility:

  • If you would like to set up auto-charge for your credit card, please complete the authorization information below:

  • The three digit Credit Card Verification number found on the back of your card
  • If you would like us to use an address other than your home address for billing and other correspondence please provide an alternate address here
  • Sign Consent after reviewing policies

    I understand these policies and I and any of my representatives now or in the future waive any and all rights to subpoena L. Alexia Camfield, LCSW and her clinical record on any current or future legal proceedings.