Patient Forms

Click to download the PDF document.

Consent for
Telehealth

Consent To
Bill Insurance

Informed
Consent

Notice of
Privacy

Office
Policies

Patient Registration Packet

This packet contains the following forms: Patient Registration Form, Credit Card on File, Informed Consent, HIPAA, and Telehealth Consent.

Patient Registration Form

Patient Information Regarding Credit Card on File Policy

Informed Consent for Assessment and Treatment

HIPAA Compliance Patient Consent Form

Telehealth Informed Consent

Authorization for Disclosure of Protected Health Information

Authorization for Release of Mental Health, Alcohol & Drug Abuse, and Other Personal Health Information

Patient Registration Packet (Spanish)

830 E. Higgins Rd Ste 112
Schaumburg, IL, 60173
(847) 592-5588

Get Insights From Us