Appointment Check In for Jamie Sellers

Appointment Check In For Jamie Sellers, LICSW

Client First – Last Name

Please Select Appointment Type

Individual or Couples Counseling

Group Therapy

Assessment

Appointment Date and Time

Have There Been Any Changes To The Following ?

Insurance Changed?

Yes

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

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

Credit Card on File Changed:

Yes

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

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Please provide any feedback or comments you would like to share in regards to the services your receiving from Bevill and Associates.