Client Intake and Disclaimer

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Upon completion of this form, I will send you a confirmation and we can discuss appointment times and any other questions you may have. Thank you.
Sincerely, Elise Walker (Arizona Crossroads).

Email *

Full Name (First, Middle, Last) *

Please Enter Date of Birth *

YYYY

Phone Number you can be reached at: *

Physical Address (Street Address, Unit #, City, State, Zip Code) *

Emergency Contact Info (Name, Phone, Relation to you)

Do you currently work with a Mental Health Professional? *

Yes

Payment Disclaimer:

As stated on the azcrossroads.net website - All payment is due upon receipt of services. If you cancel less than 12 hours before your appointment, all payment is still due as an inconvenience fee. If circumstances are out of your control, please explain and I will waive the fee.

Initial Session - $90
Established 60 Minute Session - $60
30 Minute Session with Adolescents - $45
60 Minute Session with 2 People - $75
90 Minute Session - $100

I understand that I am responsible for all payment for services rendered. The person(s) responsible, listed below, are aware of this fact (Please fill out name and contact of responsible party on line below): *

Any additional comments you would like to make:

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