Therapy / Counseling, Psychological Assessment, Other

Patient Information:

Patient's Name(Required)
Patient's Address(Required)

Parent / Guardian Information:

Parent(s)/​Guardian(s) Name:(Required)
First Name
Last Name
 
Address *if different*
Are you the legal guardian?(Required)

Insurance Information:

Secondary Insurance?
I authorize payment of medical benefits to the undersigned physician or supplier (Behavioral Solutions, LLC or Family First Center for Autism) for mental health services:
Clear Signature
I authorize the release of any medical or other information necessary to process this claim:
Clear Signature
Confidentiality Agreement(Required)
Video & Audio Acknowledgement(Required)
Clear Signature