750 Old Main Street, Suite 306, Rocky Hill, CT 06067
(860) 342-0493
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Client Consent and Agreement
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I / we have read and have been given a copy of the Routine Services and Emergencies sheet.
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Yes
I / we have read and been given a copy of the Consent to Treatment sheet. I / we give Suzanne Roberts, LCSW permission and consent to provide me / us with psychotherapy.
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Yes
I hereby attest that I am the legal parent / guardian of
and I give permission for Suzanne Roberts, LCSW to provide psychotherapy (for children under the age of 18 only).
Yes
I / we have read and been given a copy of the About Fees sheet and understand that I / we are financially responsible for this treatment and for any portion of the contracted fees not reimbursed or covered by my health insurance, including deductibles, co-insurance, and co-payments. I / we also understand that I / we will be billed $50 for any appointments that are canceled or missed without 24 hours prior notice, and that the below insurance company will not be billed for this.
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Yes
I / we authorize the release of any medical or any other information necessary to process claims based on my / our treatment with Suzanne Roberts, LCSW. I / we also authorize payment of medical benefits to Suzanne Roberts, LCSW.
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Yes
Insurance Information:
Subscriber's Name
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Email
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Date of Birth
MM slash DD slash YYYY
Insurance company
Policy number
Group number
Phone number
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Other / secondary insurance: company, policy and group numbers
Phone number
Client / Guardian Name
Client / Guardian signature
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Yes
Date of Birth
MM slash DD slash YYYY
Client / Guardian Name
Client / Guardian signature
Yes
Date of Birth
MM slash DD slash YYYY
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