Please complete the following forms and bring them to your first session.
Also, call the mental health provider listed on the back of your insurance card (or the Employee Assistance Plan your company subscribes to) and inform them you have scheduled.
Your Authorization #___________________________________
Number of Sessions Allowed :__________________________
Copay=___________________________________________
Also, call the mental health provider listed on the back of your insurance card (or the Employee Assistance Plan your company subscribes to) and inform them you have scheduled.
Your Authorization #___________________________________
Number of Sessions Allowed :__________________________
Copay=___________________________________________
Til soon, Thanks!
Celebrate. Cultivate. Care. Communicate.
| Release of Information Authorizaton | Print, Fill in, Bring to Session |
| Parent/ Child Information Form | Print and Bring |
| Susan Bramlette, LMFT, Policy and Intake Form | Please Print, Sign, and Bring to First Session |
Note: To download Adobe Acrobat Reader for free, click here.