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.