Appointment Check In for Cheri Flow

Appointment Check In For Cheri Flow, LPC

Client First – Last Name

Please Select Appointment Type

Individual – Couples Counseling Session

Group Therapy

Assessment

Appointment Date and Time

Insurance Changed?

Yes

Have There Been Any Changes To The Following ?

If Yes Please Provide Policy Number and Group Number. (optional)

Credit Card on File Changed:

Yes

If Yes, Please Provide Card Number, Expiration Date and CVV Code (optional)

Consent For Treatment

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.

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

Do Not Accept

Client Feedback – Your Feedback Matters

Please Provide Feedback on Your Experience With The Services Provide By Bevill and Associates.