Download our forms and return them below before your appointment.
INTAKE PACKET:
1. Patient Information
2. Informed Consent
3. HIPAA notification
4. Verification of Benefits (to be filled out when verifying benefits with insurance company)
Please contact your insurance company prior to your first visit to ensure a full understanding of charges that will be incurred with services.
A Verification of Benefits form is part of the initial paperwork packet. Fill that out prior to calling your insurance for an efficient experience. Please return completed form to your provider.
Provider information :
Debbie D. Sardina
NPI 1770697716
LMHC 39003185A (Indiana)
LCPC 180.005715 (Illinois)
LMHC 61537102 (Washington)
ADULT ASSESSMENT FORM
ADOLESCENT ASSESSMENT FORM
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