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Client Information

West County Psychological Associates Client Information

Name of Client(s):

Person responsible for payment of services:

*Please only include phone numbers where you prefer to be contacted and where we may leave a message.

West County Psychological Associates will provide you with an invoice after each visit which you may mail to your insurance company if you are planning to file.

I accept financial responsibility for expenses incurred at West County Psychological Associates by the above named client(s).

Please note: Your credit card information will be required to be provided at your first appointment, even if you choose to pay by check or cash.

You may provide your credit card information now by using

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