Irby Psych — Irby Psychological Services, LLC

Client Information Update

Keeping your information up-to-date ensures that we can provide seamless and efficient services. It’s important to report any changes promptly, as delays may result in a temporary pause in services until updated information is received and reviewed. Please complete the form or contact us at the email address below to update your records.

Email
billing@irbypsychservices.net

Voice/Text
(662)-228-0130

eFax

(678)-868-2843

Client's Name

First Name

Last Name

Services Receiving

Please select all services that apply:

Psychological Testing

Counseling/Behavioral Health

ABA Therapy

Social Skills Group

Speech Therapy

Occupational Therapy

Parent Training

Phone Number Update

Please provide the new phone number you would like us to update in our records.

Address Update

Please provide the new address you would like us to update in our records.

Primary Insurance Update

Please provide the updated primary insurance information for our records.

Secondary Insurance Update

Please provide the updated secondary insurance information for our records.

Medication Change

Please provide the updated information regarding any changes to your medications. This includes the name, dosage, and frequency.

Emergency Contact Update

Please provide the updated emergency contact information, including the name, phone number, and relationship to you.

Approved Pick-Up Person Update

Please provide the updated information for any changes to your approved pick-up person. Include their full name, phone number, and relationship to you for our records.

Agreement

By typing your name below, you acknowledge and agree to your responsibility to promptly update any changes to the information provided in the corresponding section. You understand that failure to report such changes may result in a temporary pause of services until the updated information is received and reviewed.

Date

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