Schedule an Appointment

Location:


401 N Michigan Ave
Suite 1200
Chicago

Call: 312-822-3436

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.
  • Date Format: MM slash DD slash YYYY
  • 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 _______________
  • Date Format: MM slash DD slash YYYY
  • 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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