Please follow the instructions to complete this form prior to attending your first appointment. If you are unfamiliar with your insurance benefits, please contact your insurance company to learn about your coverage.

This is a description of how your Protected Health Information (PHI) is used at our office.

 

This form describes your therapeutic relationship with Gahanna Counseling, LLC. Please read this form carefully and discuss any questions with your therapist. Your signature is required on the last page.

Copyright © 2017, Gahanna Counseling, LLC.

All rights reserved.

540 Officenter Place, Suite 290

Gahanna, OH 43230

(888) 336-1772