(ONLY FILL OUT IF APPLICABLE)
Is client currently under the care of a MEDICAL PROFESSIONAL?
Is client currently under the care of a NUTRITIONIST?
Is client currently under the care of a PSYCHIATRIST?
(PLEASE ONLY FILL OUT THIS SECTION IF PATIENT IS A MINOR)
Payment Information
Patient is responsible for payment at the time of sessions, unless another arrangement has been made at the initial
session. I am not a participant on most insurance plans. I would be happy to provide you with a statement to submit
to your insurance carrier on a monthly basis.
If you are unable to keep your scheduled appointment, I respectfully request 24 hour advance notice for your
cancellation, or you will be responsible for the fee.
The following is only necessary to provide if reviewed in initial session:
The following signature (parent's signature if client is under 18) is confirming their understanding of the above.
Thank you, I look forward to working with you!
Regina Katz
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.