Client Information Form – Dr. Jennifer Lager

Dr. Jennifer Lager, Psy.D.

Licensed Clinical Psychologist

GetAMentalEdge.com | DrJennniferLager.com

Phone: (703) 244-9656| Email: DrJennniferLager@gmail.com

First Name

Last Name

Date

Email Address

Cell Phone

Home Phone

Preferred Way(s) to be Contacted

Address

Date of Birth

Age

Preferred Pronouns

Gender

How were you referred to Dr. Lager?

Financially Responsible Party

Financially Responsible Party Name (if other than the patient)

Relationship (to Client)

Responsible Party Phone

Emergency Contact

Emergency Contact Name *

Relationship (Emergency Contact)

Emergency Contact Address

Emergency Contact Phone *

Payment Policy

PAYMENT AND CANCELLATION POLICIES

Payment is due in full at the time of your visit (unless otherwise agreed to in advance) and can be made by venmo, check, or cash. The initial sessions is $300 and ongoing sessions are $250. All sessions are 45 minutes in length.

Appointments not cancelled 48 hours prior to the session will be charged in full. Your signature below indicates that you have been informed of these policies, have been given the opportunity to ask any questions that you have about them, and understand your financial responsibility.

Acknowledgment *I have read and understand the above payment and cancellation policies.

Client/Guardian Signature *

Confidential Psychological Services

Please retain a copy of this signed consent form for your records.

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