PSYCH
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Call us at: 440-323-5121

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Office Forms

HIPPA
HIPAA Notice Of Privacy Practices.
 
aHIPPA FORM 
Mental Health Services Forms
If you are seeking mental health services please click below on the three intake forms. Printing out and completing the forms will allow you to save much time at your first visit. Please print all the forms and complete/sign them where indicated. Bring the forms to your first session and turn them into the secretary.
Chemical Dependency Services Forms
If you are seeking chemical dependency services please click below on the five intake forms. Printing out and completing the forms will allow you to save much time at your first visit. Please print all the forms and complete/sign them where indicated. Bring the forms to your first session and turn them into the secretary.
Download & Print: Mental Health Services FormsDownload & Print: Chemical Dependency Services Forms
aCLIENT INTAKE FORM
aFINANCIAL AGREEMENT
aOFFICE POLICIES AND PROCEDURES
aADOLESCENT INITIAL EVALUATION FORM
aADULT INITIAL EVALUATION FORM
aCOURT INVOLVED CASE FINANCIAL AGREEMENT
aCLIENT INFO AND OFFICE POLICY STATEMENT
aCD CONSENT TO TREAT
a
CLIENT INTAKE FORM
aFINANCIAL AGREEMENT
aOFFICE POLICIES AND PROCEDURES
Psych & Psych Services | Diana Santantonio, ED. S. and Associates: 750 South Abbe Road, Elyria, Ohio 44035 | Phone: 440.323.5121 | Fax: 440.323.5134
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