John Ezell, LPC, LADAC – Forms
Below are several forms to fill out to become a client of Northwest Counseling, Inc. Please download and save each document to your computer, and fill out (electronically or by hand) and return to us, whether by mail or electronically. If you run into any issues or have any questions, please call us at 479.855.5704 or email us at firstname.lastname@example.org.
Please print this document for your records.
The Informed Consent form explains the relationship between client and practitioner, confidentiality, the therapeutic process, and information about technology assisted counseling (telehealth).
The Fee Agreement explains NCI’s fee schedule, insurance claims, co-pays, co-insurance, and deductibles, as well as includes information about cancellations and returned checks.
We can store your credit card securely on file to make your visit smooth and hassle-free.
Please fill out (either electronically or by hand), print, sign (at all red X’s) and either email or bring to your first appointment. We cannot guarantee your confidentiality if you choose to transmit this form over electronic means.
Please complete one set of forms per person if a couple.