ADHD Assessment

I have been given and read the Agreement (Therapist-Patient Agreement with Chicago Psychological (Dated January 1, 2010) and I agree to its terms.
Printed Name of the Patient*
First
Signed Date:*
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)
Printed Name of the Client*
First
Signed Date:*
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 _______________
Send me the PDF to be signed to this E-mail ID

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

Adult Receiving Psychotherapy
Name
First Last
Date*
Adult Consent*
I hereby request psychological services from Chicago Psychological for myself.
Child or Adolescent Receiving Psychotherapy
Legal Guardian Name
First Last
Patient's Name
First Last
Date*
Guardian Consent
I hereby request Psychological services for my ward.
I hereby affirm that I am the legal guardian for the Patient listed above and give my consent for his/her psychological treatment from Chicago Psychological.