Behavior policy

Type NA if the question does not apply to you.

Todays Date:

I agree to be compliant to the following behavior requirements:

no-show 1-2 times can be a discharge up to the provider's discretion.

I will notify the office at least 24 hours prior to appointment to cancel my appointment.

I am responsible for making sure the behavior follow-up appointments are scheduled when the behavior coordinator calls.

I understand that I need to be up-to-date on yearly wellvisits in order to continue behavior care.

I understand that if I am self pay and are due for a yearlywell visit, that I will be charged for the well visit AND the behaviorvisit.

Patient's Name*

Patient DOB

Parent/Guardian Name Printed*

Relation to Patient*

E-Signature

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