Provena Assessment Resources
Registration Packets
| Adult Client | This packet contains the Registration Form and Professional Release to allow communication between Heartland and Provena during the assessment process. |
| Child Client | This packet contains the Registration Form, Child Background Form and Professional Release to allow communication between Heartland and Provena during the assessment process. |
Forms
| Referral Form | This form is for the referring physician at Provena to fill out and fax to Heartland. |
| Release to Physician | Complete this form if you would like to allow your assessments results to be released to your primary care physician. |
Information
| HIPAA Form | This document contains information about HIPAA and about basic procedures and policies at Heartland Counseling. |
| FAQ | This is a brochure with frequently asked questions about counseling. |
| Brochure | Heartland Counseling Brochure |
| Licensed Staff | A one page handout with introductions to our senior staff. |
| Insurance Companies | A list of which companies we are In Network with |
Assessment Materials Available