Adult Intake Form
Elizabeth Vivian, LPC, PMH-C
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  • Emergency Contact Information

  • Health & Medical History

  • Policies

    Please initial each policy to acknowledge that you have read and agree.
  • Cancellation/No Show/Late Arrival Policy
  • Payment Policy
  • Billing Services through your Insurance Provider
  • Disability/Legal Matters
  • By entering your name here, you are digitally signing this online form.
  • By signing this form, you agree to the financial responsibilities stated above and authorize Elizabeth Walters, LPC LLC to charge the credit card or debit card on file for: 1) Any applicable copays/deductibles for all appointments scheduled and to be processed within 24 hours or less of scheduled appointments; 2) Missed appointments; 3) Appointments that are cancelled with less than a 24-hour notice; 4) Non-payment of any outstanding claims of 30-days or greater; 5) A returned check by your bank. Credit card will be charged for cost of service as well as any applicable bank fees. There is a minimum $30 NSF per returned check.
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