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Therapeutic Services Agency, Inc.

Online Form

By signing below, you acknowledge your agreement to the Therapeutic Services Agency, Inc. (TSA) Office and Financial Policy Agreement and confirm you have reviewed the Client Bill of Rights; this signature page will become a part of your health record.

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Acknowledgment of Agreement
Please read the full Office and Financial Policy Agreement & Client Bill of Rights (linked above) before signing.
Acknowledgment

This signature page will become a part of your health record.

Typing your name here acts as your electronic signature.

Download the PDF instead

Submissions are transmitted over an encrypted connection and stored securely for the TSA intake team. Typing your name in a signature field constitutes your electronic signature.