📋 New Patient Forms

Download, print, complete, and bring your signed forms to your first appointment.

🔒 Your privacy is protected — forms must be physically signed
Questions?  Our team is happy to help before your first visit.
📞 Call (847) 516-2538 📅 Book an Appointment ✉️ Send a Message

Before Your First Appointment

✍️
Physical signatures are required. Several of these forms must be signed by hand before your first visit. Forms marked ✍️ Signature Required cannot be accepted without a wet signature. Please do not leave these blank.
🔏
Electronic signing coming soon. We are working on a secure online option that will allow you to complete and sign all forms digitally. Until that is available, please use the print-and-sign process above.

Download All Forms at Once

One PDF with all required new patient forms — the easiest way to get started.

⬇ Download All Forms (PDF)
Individual Forms
📄
General Intake Form
Your personal information, contact details, emergency contact, referral source, and clinical background. Required for all new patients.
Required
⬇ Download PDF
🏥
Insurance & Guarantor Form
Your insurance carrier, member ID, group number, and the financially responsible party. If you are self-pay, please indicate that on the form.
Required
⬇ Download PDF
🩺
Physician Notification & Authorization
Authorization for Behavioral Health Providers to notify your primary care physician of your treatment, as required by Illinois Law PL 86-1434.
Required ✍️ Signature Required
⬇ Download PDF
📋
Financial & Treatment Policy Agreement
Our payment terms, cancellation policy, pre-authorization notice, and consent to treatment. Must be signed by the patient or legal guardian.
Required ✍️ Signature Required
⬇ Download PDF
💻
Informed Consent for Televisits
Informed consent for telehealth and video-conferenced visits. Required if any of your appointments will be conducted via telehealth.
Required if using telehealth ✍️ Signature Required
⬇ Download PDF
👤
Minor Consent Form
Required if the patient is under 18 years of age. Must be signed by a parent or legal guardian authorizing treatment.
Required for patients under 18 ✍️ Signature Required
⬇ Download PDF
📨
Consent for Release of Information
Authorization to share your health records with a designated person, physician, or organization of your choosing. Only needed if you wish to authorize a release.
Optional ✍️ Signature Required
⬇ Download PDF
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