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New Client Information for Dr. Abrams

This form is to be completed by the individual seeking care from Dr. Abrams; if that individual is under the age of 18, the form needs to be completed by the parent or guardian

Please do not fill this out until you are asked to

*Name: *Email:
*Address:
Occupation: City/State/Zip:
Work Phone: -- Home Phone: --
Cell Phone: Date Of Birth:
Referred By:

I understand that all conversations and communications with Dr. Abrams are confidential except for reports of child abuse and threats of violence against a specific individual. Dr. Abrams will keep all of my records secure and confidential. I give Dr. Abrams permission to bill my insurance carrier for services he/she has provided to me. Should these payments come to me, I understand that they are due to Dr. Abrams.

Dr. Abrams requires 24 hours notice to cancel my appointment and if I fail to make this cancellation I am personally responsible for the entire session fee.
If you want to submit claims to your insurance company you can email a copy of both sides of your insurance card to [email protected]. You can do this at any time
If you have any life or personal history information that you think might be helpful to Dr. Abrams please email that information directly to the confidential emails of Dr. Mike Abrams at [email protected] or Dr. Lidia Abrams at [email protected]. Please enter “New Client Information” in the subject heading.