Appointment Check In For Al Bevill

Appointment Check In For Al Bevill, LPC-S

Client First – Last Name

Please Select Appointment Type

Individual – Couples Counseling Session

Group Therapy

Assessment

Appointment Date and Time

Have There Been Any Changes To The Following ?

Insurance Changed?

Yes

If Yes Please Provide New Policy Number (optional)

If Yes, Please Provide: Name on Card, Card Number, Expiration Date , CVV Code and Billing Zip Code (optional)

Has Your Credit Card On File Changed?

Yes

CONSENT FOR TREATMENT I hereby consent to the treatment provided by Bevill and Associates and its employees or designees. I authorize the services deemed necessary or advisable by my caregivers to address my needs.

Consent For Treatment

Please indicate your acceptance or non acceptance to the Consent For Treatment

Do Not Accept

Client Feedback. Your Feedback Maters

Please Provide Any Feedback or Comments Regarding The Services You Receive From Bevill and Associates. (optional)