Intake Form

Financially Responsible Party

I hereby authorize treatment by Paul Olander, MSW, JD, LCSW, NBCCH, CCTP, RRT-P, TIH.  I understand that I am financially responsible for all services regardless of insurance benefits.  I authorize Paul Olander, MSW, JD, LCSW, NBCCH, RRT-P, TIH to release information to process and secure payment for services. Full fees will be charged for appointments not cancelled 24 hours in advance (48 hours for weekend appointments).

Marital Status