Personal Growth

Better Quality of Life

Reduced Stress

Important Signature Form

    My signature below indicates that I have been provided a copy of CenterLife’s Financial Policy. I acknowledge that I am responsible for any payments not billable and/or covered by insurance. I have made payment arrangements with a credit/debit card on file and/or other payment options made available to me for services rendered by CenterLife Counseling. In compliance with health insurance contracts, CenterLife Counseling cannot waive co-pays or co-insurance amounts.

    My signature below indicates that I have been provided with a copy of the HIPAA Omnibus Notice of Privacy Practices. I understand that all medical records are kept confidential unless a separate release of information form is signed by me, authorizing the release of these medical records.
    I hereby authorize CenterLife Counseling to release my medical records to my insurance company for the purpose of processing my insurance claims. This authorization shall remain in effect as long as charges are being submitted for insurance claims processing or as long as dictated by payer.

    I hereby authorize direct payment to CenterLife Counseling of any medical benefits otherwise payable to me for services provided by a Mental Health Professional affiliated with CenterLife Counseling.

    CenterLife Counseling considers your e-mail and other contact information to be confidential. We will not disclose or sell any of your contact information to outside parties or entities.

  • Signature of Client or Personal Representative If Signed by a Personal Representative, Relationship to Client: Signature of Therapist (signature to be collected in person)