Patient Forms

Patient Forms And Payment Information

Your ONLY Homework!

(A) PaperWork And (B) Payments

(A) PaperWork

1. Copy both sides of your driver’s license. Copy both sides of your insurance card(s), if applicable. Most insurances accepted. Court evaluations are not covered by insurance companies.

2. Copy and complete the Adult Form if you are 18 or older.

3. Copy, read, and complete the Informed Consent Form.

4. Copy and complete the Health Questionnaire.

(A HIPAA Notification is available for Viewing)

(B) Payment is due at the time of each session and at the start of the evaluation process.

1. Sign up for Zelle® with your online bank account.

2. Go to “Transfer | Zelle®” at bank account page top.

3. Go to “Send Money” TO EMAIL: KW@KENFIELDWALTERS.COM Zelle is EASY, FREE, VERY FAST!

*An additional fee is required if you use Pay Pal.*

Please call to begin the process of psychological evaluation, or to schedule an appointment: (248) 737-0388