RegistrationNew patient information

Tell us about you:



Your date of birth



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Spouse/Partner (Required if attending session)



Spouse/Partner date of birth




Acceptance:
I have read and agree with the Relationship Center of South Florida (RCOSF) Office Policies.
I am aware that I am responsible for full payment of all charges for services rendered. If I decide to file for insurance reimbursement, RCOSF will provide me with statements that will include all information and codes needed by my insurance company. If I miss a scheduled appointment or fail to notify my therapist at least 48 hours in advance, I will be charged the full fee for the missed session.
I authorize RCOSF to provide psychotherapy services to me and/or the following person(s):

Date*

Date