New Client Form
Thank you for your interest in services at Behavioral Health Services.  Please complete the information below so that we may better understand your needs.  Dr. Wald will contact you shortly to schedule an appointment.   We look forward to supporting you and your family.
In Google anmelden, um den Fortschritt zu speichern. Weitere Informationen
Client First Name *
Client Last Name *
Parent/Caregiver First Name *
Parent/Caregiver Last Name *
Client Age *
Client Phone Number *
Email Address *
Name of person completing this form *
How did you hear about Dr. Wald? 
 *
Reason for seeking services
Please provide a short description of your concerns leading you to seek therapy
Insurance Information *
By acknowledging this statement, I understand that all services are considered out-of-network mental health services. All fees are due at time of service. If you are planning to submit claims to insurance for reimbursement, parents/clients are strongly encouraged to research out-of-network coverage prior to making the first appointment. Please contact us with any questions. Further information can be found on our website: WaldBHS.com
Pflichtfrage
Senden
Alle Eingaben löschen
Geben Sie niemals Passwörter über Google Formulare weiter.
Dieser Inhalt wurde nicht von Google erstellt und wird von Google auch nicht unterstützt. Missbrauch melden - Nutzungsbedingungen - Datenschutzerklärung
Google Formulare