Family Services Center is a private, non-profit, counseling agency committed to making our services available to everyone. To help us determine a fee fair to all parties, we ask that you complete the following information. We may need to ask you to produce paycheck stubs or tax information to verify your income. The person assuming responsibility must be able to legally sign this contract.
Gross monthly income (before taxes, insurance, etc), Alimony, and Child Support of each household member:
By signing below, you agree to these terms and consent to the release of any personally identifiable health information necessary to conduct treatment, schedule appointments, arrange payment, coordinate other health care operations on my behalf, request payment benefits be sent to the provider, Family Services Center and consent to the release of this any personally identifiable information to
The Responsible Party agrees to all terms and conditions heretofore discussed.