Other Forms

Please see below the following forms which may be downloaded:

1. Release of Information: to be used to give a family member access to your information as part of
treatment, for billing purposes, or to request that information from your records be sent to another provider. 
Please complete all sections of this form.

RELEASE OF INFORMATION

2. Consent for "Telehealth/Online Therapy" Services

CONSENT FOR ONLINE TELETHERAPY SERVICES

3. Credit Card Authorization: to request that charges for services be automatically charged to your credit card on file.

CREDIT CARD AUTHORIZATION


Once completed, any of these forms can be Faxed back to 586/776-3369, scanned and emailed to associatedpsych@wowway.com or mailed via standard mail to: 19900 East 10 Mile Road, St. Clair Shores MI 48080