Uncommon Therapy
Uncommon Therapy

Patient Forms

New patients will need to fill out several forms before therapy can begin. The forms are available by clicking on the icons below.

 

IF YOU ARE FILLING OUT THE FORMS ON-LINE, make a copy of the form using the SAVE AS command.  Fill in the forms in this copy, gthen email it in or bring it to your first visit.  Do not enter items directly into the blanks of the master forms below.

 

Please bring the following to your initial session:

your current insurance card(s)

your driver's license or other picture ID.  

any forms you have downloaded and filled in

 

The process usually takes no more than 5 minutes.

Client enrollment/registration form
Client Registration fill-in form 06-07-1[...]
Microsoft Word document [113.6 KB]
Client Financial Agreement
FinancialPolicy.docx
Microsoft Word document [17.1 KB]
HIPAA form
ProviderPrivacyPolicy.docx
Microsoft Word document [21.6 KB]

Note: You will need Adobe(r) Reader(r) to view PDF files. If you do not have it, you can download it for free.

Larry Moen, LPC

Where to Find Me

Uncommon Therapy

315 Cindy Drive

Fairbanks, AK 99701 

 

APPOINTMENTS:

(907) 459-8200

Office: (907) 374-8777

Text: (907) 388-8963 (best method)

Email: uncommon.alaska@gmail.com

 

 

Or use our contact form.

Office Hours

Monday - Friday 9 AM - 6 PM

Saturday and other hours by arrangement

SKYPE SESSIONS AVAILABLE

Patient Forms

click on the button bekow for on-line forms

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