Client Information
Insurance Information
NOTE: Please do not use decimal points when entering the deductible and copay amounts. For example, if your copay is $25.00, simply enter 25 - If your deductible and/or copay is $0, please enter "0" in both fields.
Parent/Guardian Information
Biopsychosocial History
Biopsychosocial History - Continued
Child/Young Adolescent Assessment
(110 questions about recent behavior)
Continued
Acknowledgements and Signatures
By signing below, I give permission to Dr. Sandra Ritter to provide counseling services to this child. I acknowledge that I have read and agree wtih the Notice of Privacy Practices and the Client Services Agreement found on her website (www.sritter.vpweb.com).