Goli Bellinger Forms

I look forward to meeting with you very soon. Please complete the forms and bring them to the first session or take the first few minutes of your session to fill them out after I greet you in the waiting area.

NOTE ABOUT PAYMENT: Your credit card is required at the time of scheduling your first session. It will not be charged until the day of your appointment. By providing your credit card you agree to the cancellation policy whereby you will be charged for your appointment unless 24-hour notice is given.

Checks or cash are preferred. A 4% discount is given for payment by cash, checks, or ACH direct debit. Please make checks payable to “Keith Miller Counseling, LLC.”  We also accept Visa, MasterCard, and Discover and American Express (see credit card form below).

The following three forms are REQUIRED for meeting with Goli Bellinger:

Client-Clinician Agreement- Bellinger

Client Data Form and Consent for Care – Bellinger

 

 

The following forms are OPTIONAL and used only when needed

Visa MasterCard Discover AmEx Form  (full fees apply to credit card users)

ACH Bank Debit Authorization Form (Discounted fees apply to ACH users or payment by check or cash).

Release of Information – Bellinger

 

 

 

 

 

Hear Keith Miller discuss why slowing the mind is so important for the body in his free online stress reduction course

Graded version of course is available for professional CE credit here