Please complete the form below and and return to us by either clicking the submit button at the bottom of the form,
or using the buttons at the bottom of the form to print it or download it in PDF form,
and then fax to: (888) 289-0255 - or mail to: P.O. Box 137 - Hawleyville, CT 06440


Click here to print this form as it appears above Click here to download the Billing Form in Adobe Acrobat .PDF format Click her to download the free Adobe Acrobat Reader
FOOTHILLS COUNSELING ASSOCIATES

BILLING INFORMATION

    PATIENT INFORMATION    
Name:       Social Security #

Date of Birth         Sex (M/F)

Telephone ( H )         Telephone ( W )

Address:

City:       State:       Zip:

Marital Status:       Emergency Contact Person:
 
Name of Spouse or next of kin:

Telephone:

Address:

City:       State:       Zip:
 
Allergies to Medications:
Pharmacy:

Telephone


Family Doctor:

Telephone
 
 
 
    EMPLOYMENT INFORMATION    
Employed by:

Address:

City:       State:       Zip:
 
 
 
Please read the following sections carefully. Then sign each section by typing your full name.
By typing your full name, you are legally signing this document.

I understand that I am financially responsible for all charges for services provided to me. I also understand that none of the services are covered under insurance plans, and I am responsible for all costs incurred as part of these services.

Signed (type your name):       Date:
 
 
 

I understand that I will be charged for all therapy sessions, telephone consultations, and emergency interventions performed between sessions. I also understand that payment is due at the time of service.

Signed (type your name):       Date:
 
 
 

Release of Information: For a variety of reasons, you may need to request a report be produced. We are happy to accommodate this process but, before it is mailed, we require a signed release and payment of the fee.

Signed (type your name):       Date:
 
 
 

I understand that I am required to give 72 hours notice in order to cancel a scheduled appointment or I will be charged for the time reserved.

Signed (type your name):       Date:

Emergency Services – Staff at Foothills Counseling will make every effort to return your calls promptly but we are limited in our ability to provide emergency services. If your call is a “Medical Emergency” please indicate such when leaving a message with the answering service and ask for the “Therapist on Call” to call you back as soon as possible. Please note that the “therapist on call” may or may not be the therapist that sees you in treatment. Please give all necessary information to the “Therapist on Call” so that he or she may help you as fully as possible. It is important that you go straight to the nearest emergency room if you feel your safety is in jeopardy. It is also important to note that patients who have their telephone caller ID blocked may make it impossible for the therapist to return their call. Please unblock that feature on your telephone when you want a call returned.

I understand that I am responsible for all charges incurred related to emergency services.

Signed (type your name):       Date:

By clicking the submit button below, you will be sending your information over an insecure connection. Foothills Counseling can in no way be responsible for the transmisions of your data. If you prefer, you can choose to print this document and then fax it or mail it to the locations below:
fax to: (888) 289-0255 - or mail to: P.O. Box 137 - Hawleyville, CT 06440

Click here to print this form as it appears above Click here to download the Insurance Form in Adobe Acrobat .PDF format Click her to download the free Adobe Acrobat Reader

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