PATIENT REGISTRATION
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The best phone number to reach you.
The best email to reach you.
PCS requires all clients attending the program to have a primary therapist/psychiatrist.
If you do not have an individual therapist enter “not applicable”
If you do not have a couples therapist enter “not applicable”
Partner Information
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Other family members who may be relevant to the patient’s therapy at PCS:
MM/DD/YYYY
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Emergency Contact Information
Please read the following and initial next to each statement to indicate your understanding:
Payment is due at the time of session or when services are rendered
PCS does not accept or process insurance or Medicare, and does not contract with any insurance plans
If I file an insurance claim and the insurance company requests information from PCS, I understand that PCS will not respond to the request and will wait to hear from me (the patient)
PRIVACY PRACTICES ACKNOWLEDGEMENT: I have received the Notice of Privacy Practices (Psychotherapy Patient Services Agreement) and have been provided an opportunity to read and review it
I agree to allow PCS to send me emails regarding events they are sponsoring and surveys pertaining to the Intensive Program (Please note we do not give email addresses or any other personal information to any other organization)
I CONSENT TO CONSULTATION AND/OR TREATMENT OF THE ABOVE MENTIONED PATIENT: