Request for Evaluations, Assessments, Letters, and Forms Completion

* If you will be requesting an evaluation, assessment, or letter issued by Cornwall Counseling, i.e., FMLA, LOA, court-ordered verification, court report, metal health examination, etc. Please provide the following information. Completing written documents is reimbursed at $120.00 per hour (one hour minimum)

Please complete this form, if you will be requesting any written documents, i.e., Leave of Absence, FMLA, Court Report, etc.

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Name

First

Last

Type of Document

Please describe how you will use the letter or form, e.g., to document a condition or diagnosis, to provide evidence of participation in a program, to provide evidence in a court proceeding, to apply for a Leave of Absence (LOA), to access Family Medical Leave (FMLA) benefits, Emotional Support Animal (ESA), etc.

Credit Card Information

* if "other," please provide the name of the issuing source

Name on Card

Credit Card Number

Expiration Date

CVV Code

Card Payment Acknowledgement and Confirmation: If Cornwall Counseling agrees that the cardholder will pay fees by credit card, debit card, or HSA card the cardholder agrees to maintain valid and updated payment information with Cornwall Counseling at all times. This acknowledgement authorizes Cornwall Counseling to charge such payment(s) to the cardholder's credit card for the services requested and satisfactorily rendered. (Cornwall Counseling will notify the cardholder BEFORE charging for any service that exceeds one (1) hour and seek approval from the cardholder.)

Email address

Phone