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 form before our first appointment.

My fee is $175 and 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 Information Form:

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: _______________