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?
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!