SMOKING CESSATION PROGRAM


Psychological HealthCare, PLLC

3300 James Street, Syracuse NY 13206 • Phone: (315) 422-0300   Facsimile: (315) 671-2191


Patient Name:

Date of Birth:

If Psychological HealthCare needs to contact you please indicate where we may call and leave a message.

Home#:
Mobile#:
Work#:

The program runs 5 consecutive weeks, the nonrefundable fee for the program is $200.

Payment is due prior to program enrollment. 

If you have any questions or concerns you can reach New Client Services at 315-422-0300 option 5.

Important Notice:  This is not a guarantee of seating until your payment is received and a Psychological Healthcare Representative calls you to confirm your attendance. Refunds for this program will not be issued under any circumstances and your understanding is appreciated.

Consent for Treatment:

I consent to this treatment agreement and agree to abide by Psychological Healthcare polices listed in this agreement. I understand that I am financially to prepay for this service.

Signature of Patient or Authorized Representative:
(Relationship to patient)  

Leave this empty:

Psychological Healthcare https://phcny.com
Signature Certificate
Document name: SMOKING CESSATION PROGRAM
Unique Document ID: a6f9055e7cde77af05d2a326b9d270b623c6cd50
Timestamp Audit
December 10, 2018 10:58 am EDTSMOKING CESSATION PROGRAM Uploaded by Annemarie Scott - arauch@phcny.com IP 24.59.188.120