PATIENT INFORMATION

 

NAME: ___________________________________________________BIRTHDATE:_________________

ADDRESS:_____________________________________________________________________________

_____________________________________________________________________________________

PHONE NUMBER:___________________________________________  CELL (    )     HOME (    )

EMAIL ADDRESS:_______________________________________________________________________

PARENT/GUARDIAN NAME (IF APPLICABLE):________________________________________________

  

PREFERRED METHOD OF CONTACT:TEXT (    )      CELL (    )      EMAIL (    )

DO I HAVE PERMISSION TO LEAVE MESSAGES ON VOICE MAIL?  YES (    )  NO (    )

EMERGENCY CONTACT (NAME/PHONE NUMBER):____________________________________________

​​​

REASON FOR WANTING TREATMENT:

 

 

 

 

MEDICAL PRECAUTIONS/CONCERNS (IF ANY):

 

AUTHORIZATION FOR TREATMENT:

The undersigned hereby authorizes Sheryl McGavin ("provider") to render to the client therapy services that the provider deems to be necessary or appropriate.

  

PAYMENT RESPONSIBILITY: 

The client, or client's parent(s)/guardian(s), shall be financially responsible for the provider's fees for services provided. Fees are payable at the time of service. Cash, check, and debit/credit card will be accepted. Provider does not bill or accept payment from any third party payers, and is not able to provide forms or additional documentation for any third party reimbursement including insurance, Workers Compensation, Motor Vehicle Accident claim or legal cases. A basic receipt for payment is all that can be provided.

  

SIGNED BY: (CLIENT OR CLIENT'S PARENT/GUARDIAN)_______________________________________

DATE:_______________________   RELATIONSHIP TO CLIENT:_________________________________

Please note:

I am no longer able to accept new clients but there are many good therapists in the Charlotte area.

Please go to www.cstcharlotte.com to find another therapist

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