New Client Form

Thank you for choosing Momentum Couseling! Please complete this form in its entirety and let us know if you have any questions!

PATIENT INFORMATION

Is the patient a minor?
Sex/ Gender

Payment Information

How will you pay for services?
Upload File
Do you have Secondary Insurance?
Who is financially responsible for this patient?
Gender

Consent to treatment

Billing Practices

By signing below, I certify that I am the patient, or the legal guardian or care-taker of said patient.
 

Upon submission, a copy of this form will be e-mailed to you for your records.

Thanks, see you soon!