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 _______________
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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