Client Information Form

  • Date Format: MM slash DD slash YYYY
  • Please include your preferred first name
  • Date Format: MM slash DD slash YYYY
    Check all that apply.
  • Check all that apply.
  • If none, select "None".
  • Please include: Previous/current medial diagnoses (specify if from physician or self-diagnoses) Prescribed and OTC Medications (specify if not-compliant)
  • Please include names of therapists (specify if previous or current).
  • If self, please type your name. If someone else, please type their name and phone number. Please note that they will have to agree to our payment policy in order to charge them for your sessions. If they do not have that on file, you will be responsible for any payments due.
  • Please type your full name to show that you understand that you are ultimately financially responsible for any balance. Houston Relationship Therapy does not bill to any third party payors and will obtain payment at the time of service or in the case of a late cancellation or no-show.
  • Refund Policy: Type your FULL NAME here to confirm that you understand that Houston Relationship Therapy does not issue refunds for any pre-paid services. A credit in the form of a Texas Relationship Therapy gift certificate may be issued should you choose to transfer your credit to another client. Pre-paid services have an expiration date of 6 months from the date of purchase. Cancellation Policy: Type your FULL NAME here to confirm that you agree to being charged the full session fee if you do not give our office greater than 24 hours' notice should you choose to reschedule or cancel your appointment. The office will charge the credit card on file. In case of a missed couples session, both parties will be charged half of the total session fee. This confirmation will be used in case of a credit card dispute.
  • Please be specific: If physician, please include name so we may thank them. If on TV, please specify program. If from an HRT client, please include their name/s so they may get $10 off their hourly rate. If from an HRT Therapist, who? If in a magazine, which one? If at an event, which one?
  • We will only contact this individual with your consent or without your consent should there be a threat to your physical safety. We may also choose to call upon 911 Emergency Services and all costs incurred will be your responsibility.
  • This field is for validation purposes and should be left unchanged.

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