Welcome!

Below are my practice policies and consent for teletherapy.

Please read and sign that you understand and agree.

Download the documents below and upload a signed copy when prompted.

PRACTICE POLICIES CONSENT

Telemental Health Informed Consent

Insurance

Please complete all of the required information:

Client Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Insurance Company

Subscriber ID

Insurance Card (Front)

FileField;MaxSize=10000;Multiple;addText=Upload_File;

Insurance Card (Back)

FileField;MaxSize=10000;Multiple;addText=Upload_File;

Practice Policies Consent

FileField;MaxSize=10000;Multiple;addText=Upload_File;

Telemental Health Informed Consent

FileField;MaxSize=10000;Multiple;addText=Upload_File;

Fee-for-Service

Please complete all of the required information:

Client Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Practice Policies Consent

FileField;MaxSize=10000;Multiple;addText=Upload_File;

Telemental Health Informed Consent

FileField;MaxSize=10000;Multiple;addText=Upload_File;