Commonwealth Psychology Associates Telehealth Registration Form

Personal Information

* First Name
* Last Name
Preferred Name
* Birth Date (MM/DD/YYYY)
* Contact Number (Number you can be reached at in the event of a technical issue during session)
* Location (Address where you will be for Telehealth sessions)
Address Line 2
* City
* State
* Zip Code
* Emergency Contact Name
* Emergency Contact Phone
* Emergency Contact Relationship

I certify that the above information is accurate, complete, and current. I will notify the staff of changes.
I understand that in the event of an emergency or in the event we believe there is a threat to your health and/or safety we may contact the emergency contact listed above.

* Minor/Client * Parent/Guardian 1 Parent/Guardian 2

** Payment Authorization (Required)

This allows for you to not have to provide your credit card at each appointment.
We will always obtain your authorization before running any charges and you have the ability to remove this saved payment method at any time.
**You will still need to have this card available for your first appointment**

* Name on Card: (Please Print as it Appears on the Card)
* Card Type:
* Last 4 digits of Card Number	XXXX-XXXX-XXXX-
* Billing Zip Code:

Authorization

I authorize Commonwealth Psychology Associates, LLC to charge the card listed above for professional services rendered, by presenting this card at each visit, or, by giving verbal permission.
This authorization shall remain in effect until I notify Commonwealth Psychology Associates, LLC of my intent to withdraw this authorization.

* Signature

* Date

Notices and agreements

** These documents contain important information about this service, your rights, and your obligations. Please review each document carefully, and read them in full. **

* Informed Consent - Please click here to read our Telehealth Informed Consent document

I acknowledge receipt of the above agreement and have read, understood, and agree to the terms.

* Client/Minor * Parent/Guardian 1 Parent/Guardian 2

* Plain Lanuage - Please click here to read our Telehealth Plain Language document

I acknowledge receipt of the above agreement and have read, understood, and agree to the terms.

* Client/Minor * Parent/Guardian 1 Parent/Guardian 2

By signing my name in the box below I attest that all information above is complete and true

* Client/Minor Signature

* Signature

* Date

* Parent/Guardian 1 Signature

* Signature

* Date

Parent/Guardian 2 Signature

Signature

Date

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