Participant's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Participant's Phone *

(###)

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Parent/Guardian's Name *

First Name

Last Name

Parent/Guardian's Home Phone *

(###)

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Parent/Guardian's Cell Phone *

(###)

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Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Address (If different from mailing)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

RELEASE OF INFORMATION & ASSIGNMENTS OF BENEFITS *

I hearby authorize IGT to provide clinical information requested by insurance companies to pay my therapist directly.

Yes, I understand that I am responsible for any charges not covered by my insurance company.

CANCELLATION POLICY *

Except in severe weather conditions or extreme emergencies, a 24-hour notice is required to avoid a $50 cancellation fee.

I acknowledge this policy.

CREDIT CARD AUTHORIZATION *

I authorize IGT to charge my credit card below for services. I undertsand that my information is saved on file for future transactions tn my account.

Card Holder's Name *

First Name

Last Name

Card Holder's Phone *

(###)

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