| Cornwall Counseling Group

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

Name *

First

Last

Dear Patient (please read)

Type of Document *

Agreement *

Explain how you intend to use the letter or form, e.g., to document condition or diagnosis, to show evidence in a court proceeding, to apply for a Leave of Absence, to access FMLA benefits, etc. *

Providing Insurance Documents *

Credit Card Information *

Name of Other Credit Card

Name on Card *

Credit Card Number *

Expiration Date *

CVV Code *

Email *

Message