Patient Registration

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You are taking the first step in unleashing your potential.

Check out our Keziah Tree Therapy flipbook to learn what you can expect in the next steps of your journey.

Your support awaits!

Keziah Tree Therapy Patient Information
Patient First name
Patient Last name
Address
Birthday
Month
Day
Year
Phone
Email
Medical History (Internal use)
Presenting Issues
Background Information
Relevant History
Patient Goals
Emergency Contact
Emergency Contact Name
Relationship to Patient
Phone
Emergency Contact Name #2
Relationship to Patient #2
Phone #2
Keziah Tree Therapy Patient Information
Patient First name
Patient Last name
Address
Birthday
Month
Day
Year
Phone
Email
Medical History (Internal use)
Presenting Issues
Background Information
Relevant History
Patient Goals
Emergency Contact
Emergency Contact Name
Relationship to Patient
Phone
Emergency Contact Name #2
Relationship to Patient #2
Phone #2
Keziah Tree Therapy Confidentiality Agreement
This agreement ensures that all client information discussed during therapy sessions remains confidential, in accordance with professional ethics and legal requirements.
Patient First Name
Patient Last name
Therapist Name
Agreement
I understand that all information shared during therapy sessions is confidential and will not be disclosed without my written consent.
I acknowledge that there are specific exceptions to confidentiality, including cases of harm to self or others, abuse, or court orders.
I agree to the terms of confidentiality as outlined by my therapist and understand my rights under HIPAA.
For any additional observations or clarifications regarding the confidentiality agreement.
Signature
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Keziah Tree Therapy Financial Agreement
Add your text
Patient First name
Patient Last name
Therapist Name
Date
Agreement Type
Payment Type

Visa

Mastercard

American Express

Other
Name on credit/Debit card
Credit/Debit card number
Expiration Date
Month
Day
Year
Billing address
CVV code
Cancellation Policy
Please note that appointments must be canceled or rescheduled at least 24 hours in advance to avoid a cancellation fee. Late cancellations or missed appointments will be subject to the following policy:
Cancellations within the
Cancellation outside of
I have reviewed the financial agreement, including session fees, payment terms, and the cancellation policy. I agree to these terms and understand my financial responsibilities as outlined in this agreement.
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