If you are coming to an appointment at the Arlington office, please:
Print and Complete our Case History and Intake forms:
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Arlington Case History Form (6 pages) and
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Arlington Policy Statement
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Arlington Insurance Policy Statement
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Arlington Self-Pay Statement
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Arlington Cancellation Policy
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Arlington Credit Card Authorization
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Permission to Videotape and Photograph
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Arlington Release of Information (2 pages)
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Arlington Privacy Practices
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Arlington Acknowledgement of Receipt of Privacy Practices
-Be sure to fill out either the Self-Pay form or the Insurance Payment Policy form. You need one or the other only.
-If you choose to have our Arlington office bill your insurance, you must fill out the Insurance Payment Policy form, as well as the HCFA 1500 form you can download here. Bring completed forms to your first appointment.
If you are coming to an appointment at the Springield office, please:
Print and Complete:
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Springfield Case History Forms (6 pages) and
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Springfield Policy Statement
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Springfield Self-Pay Statement
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Springfield Cancellation Policy
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Springfield Credit Card Authorization
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Permission to Videotape and Photograph
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Springfield Release of Information (2 pages)
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Springfield Privacy Practices
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Springfield Acknowledgement of Receipt of Privacy Practices
Bring completed forms to your first appointment.
All forms requiring a signature, need an original signature for our offices please.