Client Registration/Contact Information

Today’s Date ______________________________________________

Name (s)_______________________________________________________________________________________

Street Address________________________________________________________________________________

City_____________________________________________ Zip Code_______________________________________

Birth Date_________________________________ Email address______________________________________

Home Telephone ______________________________ (Work or Cell)__________________________________

TPCC Care Voucher Clients: Secure vouchers before making the first appointment if possible.

Fees: 1 hour session—$90                          2 hour session—$160

  • Payment is due at the time of service.
  • We accept personal checks, cash, and Visa/MasterCard credit cards.
  • We do not accept insurances. We can help you file for insurance reimbursement.
  • We comply with federal and state privacy and notification laws. By signing below, you indicate you have read and been offered a copy of these regulations.
  • By signing below, TPCC Care Voucher clients authorize us to disclose required information for reimbursement.

_______________________________________                  __________________________________________
Signature of Client or Responsible Party          Signature of Client’s Spouse