City Park Psychological Services & Associates, LLC

Lou A. Lichti, Ph.D.

City Park Psychological Services & Associates, LLC
370 Virginia Avenue
Hagerstown, MD 21740
ph: 301.733.3130
fax: 301.733.3230
lichti@verizon.net

Forms

Please fill out these forms and bring them with you to your first appointment:

Client Information Sheet

Client Services Contract and Privacy Policy

Credit Card Form

Please complete the client information sheet, the credit card form, and sign, date and complete the last 2 page s of the contract and bring them with you to your first appointment.

If you prefer, you may arrive 15 mins early to complete this paperwork you will find on a clipboard on a table in the waiting room.

Payment

We accept cash, check, or credit card at the time of service. Please complete the credit card form and bring it with you to your first appointment.

Authorization form for request/release of client information

Please complete this form and fax, send or bring it to us in order to request previous records, release our health care records, or to give us permission to talk with other health care professionals. If you are between 16 and 18, both you and a parent or legal guardian need to sign the form.

Still have questions? Please contact us anytime! We look forward to hearing from you.

Easing your mind during difficult times.

For directions to our location click here.

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City Park Psychological Services & Associates, LLC
370 Virginia Avenue
Hagerstown, MD 21740
ph: 301.733.3130
fax: 301.733.3230
lichti@verizon.net