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Check In Check Up Registration Form
Check In Check Up Registration Form
Use this form to register for your Check In Check Up session. You are invited to sign up for one or two of these solution-focused sessions that will refresh the skills and coping techniques you learned as a client.  Each session is $45. Please note that these sessions are not submitted to insurance. A current credit card is required to be on file and will be charged at the time of appointment. Check In Check Up is for previous clients not presently seeing a clinician.
8Questions
Check In and Check Up Registration Form
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  • English (US)
  • 1
    You must have previously been a client at Positive Changes Counseling Center. If you are a current client, please contact us to schedule a regular session.
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  • 2
    You must be 18 years of age or older to participate in Check In Check Up.
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  • 3
    A mobile phone number is best for us to reach you.
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  • 4
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  • 5
    We will do our best to meet your schedule with the time suggestions below.
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  • 6
    By providing Positive Changes Counseling Center, Trade Name of Deborah Disney LCSW-C, LLC my credit card information, I agree that Positive Changes Counseling Center may securely store my credit card information to be used automatically when services are rendered. I understand that my card will not be immediately charged and should my card be declined, I will provide another form of payment. My signature at the end of the Check In Check Up acts as my card signature, or the guarantee that the named party of the credit card also agrees to these terms.
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