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New Couples Therapy Intake Form

New Couples Therapy Intake Form

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Select a therapist with whom you have an appointment.

DISCLOSURES & AGREEMENTS We welcome you as a patient and appreciate the opportunity to provide you with professional care. We hope that the following information will answer your questions regarding billing procedures.

E-Sign ACKNOWLEDGEMENT AND AGREEMENT: You agree that your signature for this electronic document is valid and will be enforceable as and to the full extent of a hand-written signature as an original for this entire New Couples Therapy Intake Form, including all sections and checkboxes here within. BY TYPING YOUR FULL NAME BELOW, you agree to this E-Sign Acknowledgement and Agreement.

CONSENT: By signing your name below, you e-sign and agree that all information is yours, true and accurate. You also e-sign and agree to all acknowledgements and agreements within this document (New Couples Therapy Intake Form). Lastly, you e-sign and consent to therapy services as discussed with your therapist, including therapy session fees.

CREDIT CARD AUTHORIZATION FORM

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Credit Card(Required)
American Express
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MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Expiration Date
 
*An authorization transaction may be created and then voided when first added to our system.

*Please note that David Pearl, LCSW does not currently accept credit cards at the time of the appointment, but does keep one on file for any late payments.