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Referrals
Patient Portal
Careers
Contact Us
request an appointment
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614-388-8008
614-388-8050
[email protected]
request an appointment
Client Demographics
Client Name
Date of Birth
MM slash DD slash YYYY
Age
Sex
Race
Guardian
Type of Insurance/Medicaid
Insurance/Medicaid #
Client Address w/ Zip Code
Phone
Referred By:
Contact Number
Date
MM slash DD slash YYYY
Reason for Referral
Completed Package should include:
• Demographics
• Financial Authorization
• Initial Consent to Treat
• Hipaa Sign-Off
• Notice of Privacy Practice
• Client's Rights
• Welcome Letter Agency Inoformation (optional)
