Forms

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.

Form NumberDownload and fill out at homeFill out form at home
1  Informed Consent for Counseling Services (10 pages) Please read prior to beginning treatment
2 Client Information and Consent (4 pages) We need original copy signed
3 Release of information We need original copy signed
4  Adult developmental history (in process of updating) Coming Soon!!!!!
5  Adult and Teen basic symptom & problem checklists
6 Adult Bipolar Disorder Screening Questionnaire
7 Adult Pre-Therapy Screening
8 Adult Comprehensive Assessment
9 Marital assessment
10 OCD Assessment
11Child Screening Checklist
12Child Development History FormComing Soon!!!!!
13Childhood Anxiety Specific Screening Form
14Cigna EAP FormWe need signed original
15Magellan EAP FormWe need signed original
16Magellan EAP Form – USPS EmployeesWe need signed originals
17Horizon Healthcare EAPComing Soon!!!!!
18Horizon Healthcare Rights and ResponsibilitiesComing Soon!!!!!
19Ceridian EAP (Lifeworks)Coming Soon!!!!!
20Employees Resource Systems (ERS) EAPComing Soon!!!!!
21Primary Care Physician notice (HMO Plans ONLY!!!) We need signed originals
22Informed Consent for a Free Consultation Form We need signed originals