for further information

Please fill out the form below. You will be asked to sign a copy of the form on your first visit.


Name *
Name
Phone Home *
Phone Home
Phone Cell
Phone Cell
Address
Address
Are you currently under a physician's care?
Currently using medication?
Have you seen a therapist in the past?
Emergency contact person's name
Emergency contact person's name
Contact's phone
Contact's phone
For insurance billing, I authorize the release of the minimum medical or other information necessary to process the claim.
I authorize payment to Hal Childs, PhD, MFT, of medical benefits for mental health services provided by Hal Childs, PhD, MFT.
I agree to the fee (below) per session.
$
I have read the information on this page and agree to the stated conditions.
Date
Date

GUIDELINES THAT INFORM OUR WORK TOGETHER

Confidentiality: What you talk about in therapy is confidential and protected by law. Your right to privacy is respected, and it is important to have a safe environment to work in. There are three times when the law requires me to disclose confidential information without your written permission:

  • If there is a reasonable suspicion of child or elder abuse.
  • If there is a resonable suspicion that you present a danger of harming someone else.
  • If it appears likely that you will harm yourself.

Cancellations: If you need to cancel an appointment I ask that you notify me by telephone at least 48 hours in advance of your appointment. I am willing to try and reschedule last minute cancellations within the same week, or two hours in the next week, at no additional charge. If another appointment cannot be made payment for the missed hour is expected. You would be responsible for the full amount usually billed to insurance, or a third party.

Payment:

  • Payment is expected at each session unless we make other arrangements.
  • If you plan to use your health insurance to help pay for counseling, it is your responsibility to know what is required for submitting claims. We can submit claims with me as an out of network provider. I am happy to provide assistance in filling out forms and working with the insurance company.