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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]
HELPFUL FORMS

If you're a first-time client, please review and complete the following forms, bring them to your first session.

  • Adult Intake Questionnaire or Child/Adolescent Intake Questionnaire
  • Concerns Checklist
  • Informed Consent Form
  • Client Information Form
  • Consent to Pay for Non-Covered Charges
  • Caffeine Consumption Questionnaire
  • HIPAA Privacy Notice (this is for you to keep)

 For Couples Therapy please complete the following forms:

  • New Client Information Form
  • Client Intake Form (for Couples Therapy)
  • Informed Consent Form
  • Locke-Wallace Test
  • Weiss-Cerretto Inventory
  • Finding Your ACE Questionnaire
  • SCL-90
  • HIPAA Privacy Notice (this is for you to keep)

If you would like me to coordinate care with another provider (for example, your psychiatrist, endocrinologist, etc.), complete this form:

  • Release of Information Form

 


 

Adult Intake Questionnaire

or

    Child/Adolescent Intake Questionnaire

 Consent to Pay
Informed Consent Locke-Wallace Test
Release of Information  Weiss-Cerretto Inventory

New Client Information Form

          

Client Intake Form (for Couples Therapy)

 SCL-90
Sleep Diary Health Questionnaire
Mood Diary Caffeine Consumption  Questionnaire
HIPAA Finding Your ACE Questionnaire


 Sliding Scale Application
Concerns Checklist

 

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