Registration

ONLINE REGISTRATION FORM

Your Name:

Date of Birth:

E-mail Address:

Home Address:

Home Phone:

Employer:

Occupation:

Work Address:

Work Phone:

Driver’s License Number:

Emergency Contact Name:

Emergency Contact Phone:

Referred By:

Physician:

Medical Conditions:

Current Medications:

FEE AGREEMENT:

Professional fees are based on $125 for a standard 50 minute session. Psychological assessments, consultations, and reports are billed at $100 per hour. Brief professional services are billed at $35 per 15 minutes or any part thereof, including telephone consultations. Generally, fees range between 2 to 3 dollars per minute, according to the particular service or pricing plan.

I have read and understand the client information and office policy page, and I wish to work with Dr. Silva.

I have read and I understand the above fee agreement, and I agree to its terms.

Click picture to schedule an appointment.

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