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216.533.4966
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About
Marissa Ferrer, LISW
Patti Verde, LISW-S
What We Do
Insurance/Privacy
Insurance
Notice of Privacy Practices
Consent for Treatment
Office Procedures
Client Registration
Consent for Telehealth
Contact Us
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Let's Connect
in 3 easy steps!
3. Consent for Treatment Form
1. Client Registration
First Name
Last Name
Email
Gender
Date of Birth
Best Phone Number
Ok to leave a message or text?
*
Yes
No
Home Address City, State & Zip
Emergency Contact: Person Name, Relationship & Phone Number
I am aware that this office is HIPAA compliant and that my signature indicates that I am in agreement with providing the above information.
Submit
Thanks for submitting!
2. Insurance Information
First & Last Name of Insured & Relationship
Home Address City, State & Zip
Best Phone Number
Date of Birth
Employer and Address
Primary Insurance and Claim Address
Insurance Identification Number
Insurance Group Number
Secondary Insurance, Identification Number & Group Number
I am aware that this office is HIPAA compliant and that my signature indicates that I am in agreement with providing the above information.
Submit
Thanks for submitting!
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