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

  • 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
  • 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.
  • Date Format: DD slash MM slash YYYY