Mona A. Kalhor, PSY-D, MBA

Licensed Forensic and Clinical Psychologist 

Cell: (954) 732-1103 - e-mail:



Patient’s   Full Name:         SS#: 

Date   of Birth: Sex: F M Age: Phone:

Home   Address

Drivers   License #: 

Family   Physician:  Referred   by:

Person   to Contact in Emergency: Phone:

Insurance   Company:

Insured’s   Primary Ins, C: ID: NO: Group NO: 

I   attest that I read the limits of confidentiality and treatment contract as   well as 


Office Billing and Insurance policy:

1-  I authorize use of this form on all of my   insurance submissions.

2- I   authorize the release of information to my insurance company(s).

3- I   understand that I am responsible for the full amount of my bill for service   provided.

4- I   authorize direct payment of my service provider.

5- I   hereby permit a copy of this to be used in place of any original.

6- It   is your responsibility to pay any deductible (if insurance accepted) at the   time of service.

7- There   will be a $50 for a return check.

8- There   is a 48 hrs cancellation policy which requires that you cancel you   appointment 24 hours in advance between the hours of 8 am- 4 pm, Monday   through Friday to avoid being charged $50 for no show. 


Name:  ID:

Signature: Date: