Primary Care Physician Notification Form

ICC Inc. Media Services Portal: Forms

This form is part of the Client Intake Packet. It was last updated May 17, 2021.

Innovative Counseling & Consulting, Inc.

Primary Care Physician Notification Form

Part I: Physician Information

Part I: Client Information

Part II: Letter to Physician

I am writing this letter to inform you that I am providing mental health counseling services to your client, _____________________________. Please contact me at your convenience, if you would like to discuss the treatment I am providing or if you have any questions or concerns at the following address:

Innovative Counseling & Consulting, Inc.

1063 14th Place
Des Moines, IA. 50314
Phone: 515-235-5224

Thank you for your cooperation in this matter.

Sincerely,
Innovative Counseling & Consulting, Inc.
Cc: File

Part III: Signature

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