Appointment Request, Information, Informed Consent
Patient’s Last Name
Date of Birth
Name of Parent or Legal Guardian (if applicable)
Relationship to Patient
Emergency Contact Name & Phone Number
Email Address ( if it’s ok that I contact you this way)
Cell Phone Number
Other Phone Number
Type your Scheduling Request Here
I prefer not to use insurance, and I am not going to inform Dr. Klein Psychological Services, inc that I have insurance. I wish not to have a third party involved in my healthcare decisions and I want my health information to be entirely private. I realize that if Dr. Klein happens to be contracted on my insurance panel I cannot receive reimbursement for expenses.
Please upload pictures of the front and back of your insurance card if you wish to use insurance.
Insurance Plan Type: (EAP Not Accepted)"
Other (Specify below)
Policy Holder Date of Birth
Name of Psychiatrist if you have one: (Optional)
Office Policies & Informed Consent, Financial Agreement, HIPAA Notice
I agree and consent to all policies found at https://drkleinpsychology.com, and which are available for my review in the link above. I have had the opportunity to ask questions about all policies.
Patient(s) or Legal Guardian’s Signature