Attachment Disorder Treatment

attachment and bonding center of ohio

gregory c. keck phd

Application Packet and Processing Information

Financial Agreement

Date____________

I, ______________________ (recipient) or ______________________ (parent, legal guardian, or custodian of minor) am aware that services provided for ______________________ in this office will not be billed to Medicaid, and I agree to be liable for the fee for service.

Signature _____________________

If other than parent:

Title _________________________

Agency _______________________

Gregory Keck, PhD

Attachment and Bonding Center of Ohio

Cleveland Office 440-230-1960
12608 State Road
Suite 1
Cleveland, Ohio 44133

Columbus Office 614-850-9800
3966 Brown Park Drive
Suite H
Columbus, OH 43026