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About Us
Services
Referrals
Patient Portal
Careers
Contact Us
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)
