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Forms

 

 

All clients should read form number 1, the Informed Consent prior to the first appointment.

If you are an adult coming in for individual therapy then fill out form numbers 1 and 4

If you are coming in as a couple then each spouse should fill out form numbers 1, 4 and 8

If therapy is for an adolescent (12 and older) then parents should fill out numbers 1,4,10 and 12.

If therapy is for a child then parents should fill out forms 1,10 and 12.

 

Form

No.

Download and fill out at home Fill out form online

1

   Informed Consent for Counseling Services (10 pages)

Please read prior to beginning treatment

2

   Client Information and Consent (4 pages)

we need signed original
3    Release of information we need signed original
4

   Adult developmental history (in process of updating)

not yet available online
5

   Adult and Teen basic symptom & problem checklists

not yet available online
6

   Adult Bipolar Disorder Screening Questionnaire

not yet available online
7    Adult Pre-Therapy Screening   fill out on-line now
8
9   fill out on-line now
10    OCD Assessment   fill out on-line now
11

   Child Symptom Checklist  (in color) or (in black & white)

  fill out on-line now
12

   Child developmental history (in process of updating)

not yet available online
13
not yet available online
14 we need signed original
15 we need signed original
16 we need signed original
17 we need signed original
18 we need signed original
19
   Ceridian EAP (Lifeworks) (2 pages)
we need signed original
20 we need signed original
21    Primary Care Physician notice (for HMO plans only) we need signed original
22    Informed Consent for a Free Consultation we need signed original

 

Notice regarding children age 12 and older:

Children who are 12 and older must sign a release of information for the therapist to speak with their parents about psychotherapy.

In Illinois, the right to privacy for mental health records begins at age 12, so, children 12 and older must sign a release of information in order for PSC to release their medical records to any third party, including their parents. Parents of children also have a right to confidentiality.

 

All forms are copyright protected by Personal Solutions Counseling 2002.