Counseling Registration - Relationship Center of South Florida

Please complete the following information for our records. Your information will be transmitted securely using the highest encryption methods possible for your safety.

Name(Required)

First Middle Last

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code

Email(Required)

Phone(Required)

Occupation

Employer

Emergency Contact

Phone

Relationship

Primary Care Physician

Phone

Referred by

Phone

Spouse/Partner (Required if attending session)

If you're attending as an individual, please use "N/A" in the required fields.

Name(Required)

First Middle Last

Date Of Birth

Mobile Phone(Required)

Home Phone

Consent

I have read and agree with the Relationship Center Of South Florida Office Policies.

I am aware that I am responsible for full payment of all charges rendered at the time of service. For those who use health insurance, co-payments are due at the time of service, and if the insurance deductible is not met, the full fee will be paid at the time of the session. I have read and agree to all policies regarding the use of health insurance. 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 Relationship Center Of South Florida (RCOSF) to provide psychotherapy services to me and/or the following person(s):

Signature(Required)

(Client or authorized party)

Date(Required)

Signature

(Attending Spouse or Partner)

Date

RegistrationNew patient information

Spouse/Partner (Required if attending session)

Consent

Center Information

Therapy & Counseling

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