Form — Jila Behnad MFT

Step 1

Sign the Acknowledgement of Receipt of Informed Consent and Notice

Step 4

Fee

The fee is $250 for 50-minute session.

I authorize Jila Behnad, MFT to charge my credit card for therapy/consultation sessions. By signing below, I certify the above information is true, accurate and that I am an authorized user on the account. I authorize Jila Behnad, MFT to store my credit card information and charge any fees due, based on my responsibility listed in intake paperwork, which includes any session completed or scheduled and not cancelled prior to 24 hours of the appointment time.

Name

As printed on card

First Name

Last Name

Credit Card Number

Expiration Date

MM/YY

CVC

3 digit code on back of card

Billing Zip Code

Client Printed Name

First Name

Last Name

Client Signature

First Name

Last Name

Step 5

Fill out the Application for Service

Form

Name

First Name

Last Name

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone (cell)

(###)

###

####

Telephone (home)

(###)

###

####

May I leave a message at either number?

Occupation

Employer

Date of Birth

MM

DD

YYYY

Age

Gender

Marital Status

Emergency Contact #1 Name

First Name

Last Name

Emergency Contact #1 Telephone

(###)

###

####

Emergency Contact #2 Name

First Name

Last Name

Emergency Contact #2 Telephone

(###)

###

####

Current Medications

Any Allergies?

Who lives in your home with you? State their name, age and relationship please.

Step 6

Recording Consent

In order to constantly improve my counseling skills, I often like to record sessions. If you are comfortable with this I need your written permission. Our work in counseling will not be affected by the recording and you are free to say no. If at any time you change your mind we can stop the recording. I give permission for Jila Behnad, MFT to record our counseling sessions for use in peer supervision meetings and for use in meeting with a supervisor. I understand that my confidentiality will be protected at all times. If either a supervisor, supervisee or researcher knows me in any way whatsoever they will not view the recording and will keep my confidentiality as per standard professional guidelines.

Step 7

Authorization to Release Confidential Information

I hereby authorize Jila Behnad to release confidential information obtained during the course of my work. This Authorization permits the release of any and all information necessary.

Release confidential information to:

For the following purpose:

The Authorization shall remain valid until:

MM

DD

YYYY

By:

Date:

MM

DD

YYYY

Read the Informed Consent

Read the Good Faith Estimate

Sign the Acknowledgement of Receipt of Informed Consent and Notice

Fee

Fill out the Application for Service

Recording Consent

Authorization to Release Confidential Information