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 2019

CLIENT PERSONAL DATA RECORD
Name of Client:*
First Last
Client's Date of Birth:*
Month
Day
Year
Mailing Address:*
Street Address City State ZIP Code
Home Phone:
Cell Phone:
Email Address:
Signature allowing unencrypted email & text messaging between myself & Alexia Camfield LCSW*
Referred by:
Financial Responsibility:
Person financially responsible for this account:*
First Last
Signature:
If you would like to set up auto-charge for your credit card, please complete the authorization information below:
Credit Card number:
Expiry Date:
Month
Day
Year
CCV Number
The three digit Credit Card Verification number found on the back of your card
Please enter a number from 000 to 999.
Name as listed on card:
Signature of authorized user:
Consent for Treatment / Services & Receipt of HIPPA & Policies & Procedures
I give full consent for myself or my child to receive outpatient mental health services until I notify Alexia Camfield of any changes or until it is determined that services are no longer necessary. I certify that I have the legal right to seek and authorize services for myself or my child. I have been provided with a copy of the Policies & Practices to Protect the Privacy of Your Health Information and the Office Information & Office Policies. I understand and accept those policies and practices. I give consent for the office of Alexia Camfield to contact me and disclose my health information as described in those policies for treatment, payment and health care options.
Printed Name*
First Last
Date*
DD slash MM slash YYYY
Signature*

Online Therapy Form

Therapy Form 2019

CLIENT PERSONAL DATA RECORD

Financial Responsibility:

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

Consent for Treatment / Services & Receipt of HIPPA & Policies & Procedures