* = required
Emergency Contact Information
Reason for Referral
FINANCIAL ASSISTANCE INFORMATION
Note: The agency receives several grants and contracts for substance abuse treatment and we may provide financial assistance to those clients involved in our substance abuse treatment program.
I am hereby authorizing Seashore Family Services and it’s representatives to communicate with me via:
Note: If you have any questions about this form, speak with one of our staff members at our offices; Brick. Office 732-920-2700 or Toms River office: 732-244-1600 or email us at firstname.lastname@example.org.
I understand and agree that, I am ultimately responsible for the balance of my account for professional services rendered. I have read all the above information and have completed or verified the above answers. I certify this information is true and correct to the best of my knowledge and that I will notify SFSNJ staff of any changes in the above.
Excluding exceptional circumstances, clients will be bill at the current cancellation fee for appointment not cancelled 24 hours in advance.
Please sign below using mouse on desktop, or stylus/finger on tablet or phone.