Lex Burgeson, Master Level Splankna Practitioner​

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Download, complete, sign, date and bring each of these forms to your first appointment:

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INTAKE Form: Please print and sign

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DISCLOSURE STATEMENT: Please print and sign. If the client is a teen the age of 12 or over, he/she must ALSO read and sign this form.

 

PAYMENT POLICIES: Please print and sign.

 

HIPAA ACKNOWLEDGEMENT: Please print and sign

 

HIPAA DOCUMENT: Please read. Print ONLY if you'd like to keep a copy for your records.

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CONSENT TO TREAT MINOR CHILDREN (for children under age 15)

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