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ASSESSMENT SESSION FORMS
Before your first session you may like
to download the Patient Information Sheet, the Initial Assessment Form and the HIPAA Privacy Information & Confidentiality
Form and bring the completed forms with you to the first appointment. Blank forms will also be available in the waiting room
but please arrive 15 minutes early for your appointment to give yourself enough time to complete them.
If you are using Humana insurance, please download the forms on the Humana Forms page.
Click here to download the Initial Assessment Questionnaire
Click here to download Patient Information Sheet
Click here to download HIPAA Privacy of Information Policies Sheet
If you would like me to submit your insurance claim to
your insurance company on your behalf, please complete the form below:
Click here to download the insurance submission form
If
you would like me to be able to communicate or release information regarding your therapy to other doctors or for disability
records, please download and complete the Consent to Release Information Form.
Click here to download a Release of Information Consent Form
CREDIT CARD PAYMENT AUTHORIZATION
If you would like to authorize session
payments using your credit or debit card, please download this form and fax the completed form to 847 562-9352.
Click here to download a Credit Card Payment Authorization Form
REGULAR SESSION FORMS
These are forms that we have used in our
sessions. Please download more copies if you need them.
Click here to download a Weekly Thought Journal
Click here to download the Postpartum Depression Screening Questionnaire
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