Client Information

West County Psychological Associates Client Information

Name of Client(s):

First Name

Last Name

First Name

Last Name

Person responsible for payment of services:

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

First Name

Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Employer

Phone

Spouse's First Name

Spouse's Last Name

Spouse's Employer

Spouse's Telephone

Spouse's E-mail Address

Referred by

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.

Please charge my credit card for each visit

I will pay by check or cash at the time of my visit

You may provide your credit card information now by using

Consent(Required)

I fully understand and agree to the above stated terms.

Your First and Last Name(Required)

Date(Required)