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Gary Conway, LMHC, BCB
(317) 571-0170 ext. 119
8935 N. Meridian St.
Suite 107
Indianapolis, IN 46260
USA

[email protected]
EAP FORMS

Please complete the following before your first EAP session:

  • Demographic Information Form
  • Consent to Treatment Form
  • Intake Form
  • HIPAA (This is your privacy rights. You may download this form for your files)

Optional Forms to completed if your counselor requested:

  • SCL-90
  • ACE

 

Demographic Information Form

Consent to Treatment Form

Intake Form

SCL-90

ACE

HIPAA