Raleigh Psychotherapy Adult Biopsychosocial Face Sheet (Page 2 of 2) in pdf

Raleigh Psychotherapy Adult Biopsychosocial Face Sheet Page 2

Raleigh Psychotherapy, PLLC

4016 Barrett Dr, Suite 104

Raleigh, NC 27609

Beverly Simmons, PhD, LCSW

919-824-9102

Responsible Party Information

** Only provide information in this section if the responsible party is someone other than the patient.

Name - Last: _______________

First: _______________

Middle: _______________

Address - Street: _______________

City: _______________

State: _____

Zip: __________

Home Phone: _______________

Mobile Phone: _______________

Work Phone: _______________

Email address: ______________________________

Relationship To Patient: _________________________

Acknowledgement

I understand that I am required to give Dr. Beverly Simmons or Raleigh Psychotherapy, PLLC 24 hours

notice if I need to cancel an appointment, and I understand that Raleigh Psychotherapy, PLLC will bill me

for the full fee if I fail to give her the required notice.

_____________________________________________

______________________

Signature

Date

Rev. 2013

A pdf of this form is available at

Page: 2

Raleigh Psychotherapy Adult Biopsychosocial Face Sheet Page 2