SMOKING CESSATION PROGRAM
3300 James Street, Syracuse NY 13206 • Phone: (315) 422-0300 Facsimile: (315) 671-2191
Date of Birth:
If Psychological HealthCare needs to contact you please indicate where we may call and leave a message.
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.
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)
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Document Name: SMOKING CESSATION PROGRAM
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