Scottsdale Therapist
Susan Charney Scottsdale Therapist
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tel: 480-467-0223
fax: 480-467-0229

Click here to book online

6619 N. Scottsdale Road

Scottsdale, AZ 85250 (Map)

Patient Forms

If possible and to save time, please print & fill these forms out prior to our consultation.

Medical History Form

Patient Information

Insurance Information Form

Treatment & Authorization Form

Insurance Copay form

Credit Card Authorization Form

Acknowledgment of receipt of notice of privacy practice

Child & family information form

 

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Susan Charney
6619 N. Scottsdale Road Ste 21
Scottsdale, AZ – 85250
@ El Dorado Square