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IntakeQ Forms

Intake Paperwork

Intake Packet
Informed Consent & Financial Covenant Agreement ONLY
Intake Packet WITHOUT Informed Consent and Financial Covenant
PSYCH Informed Consent & Finacial Covenant Agreement
Release of Information CLIENT
Release of Information COMPLETED BY FAMILY MEMBER
Title XX Application
Covenant Agreement ONLY
Financial Covenant Agreement ONLY
Informed Consent ONLY
Minor Consent ONLY
PHQ/GAD ONLY
Psycho-Social Questionnaire
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Office Hours:

Monday - Thursday: 8:30am - 8:00pm

                   Friday: 8:30am - 5:00pm



Intake Hours:

Monday - Thursday: 8:30am - 5:00pm

                   Friday: 8:30am - 4:00pm

Locations

Tipp City

Main Offices

7695 S. Co. Rd. 25A

Tipp City, OH 45371


Office: 937-667-4678

Fax: 937-667-4963


Centerville

Fairhaven Church

637 E. Whipp Rd.

Centerville, OH 45459

Policies & Procedures
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