- Bevill and Associates Behavioral Health

Appointment Check-In Michele Sellers, LPC

Client First and Last Name

Appointment Type

Appointment Date and Time

Have There Been Any Changes To The Following ?

Insurance Changed?

Yes

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

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. (optional)

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

I accept

I do not Accept

Feedback. – We Value Your Feedback!

Please provide any feedback or comments you would like to share in regards to the services you'r receiving from Bevill and Associates. (optional)