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

    Please note that I only accept certain insurance plans at this time. If I am not credentialed with your insurance provider I am happy to offer reduced rate fees.
  • Emergency Contact Information

  • I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Elizabeth Vivian, LPC, PMH-C may use my healthcare information and may disclose such information to my insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits of the benefits payable for related services. This consent will end when my current treatment plan is completed or 12 months from the date below.
  • By entering your name here, you are digitally signing this online form.
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  • Health & Medical History

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