Nye Law Group – TCS Sign Up Form

Telephone Consultation Service Application/Agreement

"*" indicates required fields

Name of Agency/Practice*

Agency Phone Number*

Address*

Street Address Address Line 2 City State ZIP Code

Subscription Package and Payment Plan*

All persons providing mental health services with the agency must be included in your subscription plan

Total Number of Clinicians*

All persons providing mental health services with the agency must be included in this count

Please enter a number greater than or equal to 1.

Contact Information

Contact information for all clinicians. The first clinician entered will be considered the primary subscriber.

Name	Phone	Email	Licensure	Actions

There are no Clinicians.

Agreement*

I(We) hereby enroll in the Nye Law Group, Ltd. Telephone Consultation Service (TCS). I(We) have read and understand the terms of the service identified in the brochure accompanying this application. I(We) understand that the service will commence upon receipt by Nye Law Group, Ltd. of this application/agreement and accompanying check or credit card payment for a one-year or monthly subscription, and my subscription will automatically renew based on the chosen subscription method thereafter unless and until Nye Law Group, Ltd. is notified of cancellation of the TCS subscription no later than 30 days prior to the renewal date. I(We) shall be billed for the service each month and if a credit card is used to subscribe that credit card will be automatically charged on or before last day of the month for each subsequent month. (Initial annual subscriptions processed after 01-31 will be processed pro rated monthly through 12-31 of the next full calender year so that all subsequent years will expire at the end of the calendar year.)

I have read and agree to the above terms and conditions

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Phone

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