Your reliable protection in jurisprudence. Our qualification provides the opportunity solve the problems of any complexity.
contact info

4096 N Highland St, Arlington
VA 32101, USA
legalor@demolink.org
800 1234 56 78

Mon-Thu: 9:30 – 21:00
Fri: 6:00 – 21:00
Sat: 10:00 – 15:00
newsletter
Be the first to find out about exclusive deals, the latest Lookbooks, and top trends.
© 2018 Legalor. All rights reserved. Terms and Conditions | Privacy Policy

Schedule an Appointment

Locations:


605 N Michigan Ave Ste 401, Chicago



250 Parkway Dr Ste 150, Lincolnshire

Phone

Local: 312-646-5324

HIPAA Authorization V2

  • I have been given and read the Agreement (Therapist-Patient Agreement with Chicago Psychological (Dated January 1, 2010) and I agree to its terms.
  • Signature of the Adult if Patient _______________ Date Signed _______________
  • Signature of Minor Client (if age 12-17): _______________ Date Signed _______________
    Signature of Legal Guardian for Minor Client: _______________ Date Signed _______________
  • I acknowledge that I have received the HIPAA Notice Form (Notice of Chicago Psychological Policies and Practices to Protect the Privacy of Your Health Information)
  • Signature of the Adult if Client _______________ Date Signed _______________
  • Signature of Minor Client (if age 12-17): _______________ Date Signed _______________
    Signature of Legal Guardian for Minor Client: _______________ Date Signed _______________
[asp_product id="885"]

Do fill out the form below and we will be ready before you arrive :)

Treatment Consent Form

  • Adult Receiving Psychotherapy

  • Child or Adolescent Receiving Psychotherapy