Welcome to my practice and thank you for making the decision to work with me.
My office is located at 1640 Valencia Street. The door code is 4567#. Please come up one flight of stairs and open the door to suite 2B, (the restroom is down this hall another door down) and have a seat in the waiting area and I will get you at our time.
Please fill out and email the CLIENT INFORMATION form before our first appointment.
I accept cash or check at the start of the appointment.
I look forward to meeting you.
Warmly,
Dana Cohen PsyD Licensed Clinical Psychologist CA License #: PSY29203
Client Contact Information
Name: __________________ Date of Birth: ___________________
Address: ________________________ E-mail: _______________________
Phone Numbers: Okay to leave message?
Home: ____________________________ yes no
Work: ____________________________ yes no
Cell: ____________________________ yes no
Emergency Contact
Name: _____________________________ Phone: ______________________
I give permission to contact in case of emergency: yes no
Psychiatrist
Name: _____________________________ Phone: ______________________
Primary Physician
Name: _____________________________ Phone: ______________________
Credit Card Information
Name on Card ______________________________________________
Credit Card Type ______ Number______________________________
Expiration _______ Security Code_____
I authorize Dr. Dana Cohen to bill the credit card (above) for charges associated with treatment of the patient named above. Charges will be made to the credit card on or after the dates of service, and will include only those services contracted.
Signature of Cardholder: ________________________ Date: _______________