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Please read and review the following before proceeding
to the New Client Information Form.
I agree to contract with Dr. John A. Garlock to provide
me with the clinical services I require, which may include
all or part of the following:
- Initial Evaluation
- Treatment Plan Development
- Standardized Counseling Assessment (if required)
- Direct Counseling and Psychotherapy Services for
myself and/or other designated family members.
- Specialized Assessment Of Specific Problem Area
such as depression, AD/HD, etc.
- Referral to approved and qualified Medical Personnel
if required and with my approval or to any other appropriate
treatment specialist; and
- Maintenance of appropriate case and billing records
required to provide these clinical services.
These services are to be provided to the individual
named in the New Client Information Form.
- I further agree to have Dr. Garlock provide mutually
agreed upon sessions consisting of the above referenced
services to the designated individual listed in the
New Client Information Form. I do understand that
this estimated session total can be renegotiated at
any time by either myself or Dr. Garlock depending
on my treatment needs.
- I agree to pay the negotiated and agreed upon fee
charged by Dr. Garlock for those professional services
listed above that Dr. Garlock renders.
- I understand that I can terminate the services that
I am receiving from Dr. Garlock at any time. I further
do understand that I have no moral, legal, or financial
obligation to complete the number of sessions that
are listed above. I further agree that I am contracting
only to pay for those professional services that are
actually provided by Dr. Garlock.
- The payer source for services that are to be provided
by Dr. Garlock will be listed in the New Client Information
Form.
I agree to pay the payment/co-payment amount due each
session to Dr. John Garlock. I do understand that I
will be responsible for the unpaid portion of the fee
for services rendered that are not paid for by the payer
source listed in the New Client Information Form.
By clicking on the "Continue" button below,
I certify that I have read, understood and agree to
the above document.
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