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FORM INDEX PAGE

INSURANCE FORM

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NEW CLIENT DEMOGRAPHIC

new client demographic

consent for treatment

CONSENT FOR TREATMENT
HIPPA

confidentially & cancellation  

CANCELLATION

release of information form

optional

RELEASE OF INFORMATION
BETSY 1

TELE- PSYCHIATRY TELE - THERAPY CONSENT 

TELE - PSYCH PHONE CALL

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LOCATION 1:

215 North Main Street

Algonquin, IL 60102

Phone: 224-678-9033

Fax: 224-678-9493

Email: Dr.Lendvay@comcast.net

LOCATION 2:

1644 Colonial Parkway

Inverness, IL 60067

Phone: 847-776-4500

Fax: 847-776-4724

Across from Harper College

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