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 Number | Download and fill out at home | Fill out form at home |
1 | Informed Consent for Counseling Services (10 pages) | Please read prior to beginning treatment |
2 | Client Information and Consent (5 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 | |
11 | Child Screening Checklist | |
12 | Child Development History Form | Coming Soon!!!!! |
13 | Childhood Anxiety Specific Screening Form | |
14 | Cigna EAP Form | We need signed original |
15 | Magellan EAP Form | We need signed original |
16 | Magellan EAP Form – USPS Employees | We need signed originals |
17 | Horizon Healthcare EAP | Coming Soon!!!!! |
18 | Horizon Healthcare Rights and Responsibilities | Coming Soon!!!!! |
19 | Ceridian EAP (Lifeworks) | Coming Soon!!!!! |
20 | Employees Resource Systems (ERS) EAP | Coming Soon!!!!! |
21 | Primary Care Physician notice (HMO Plans ONLY!!!) | We need signed originals |
22 | Informed Consent for a Free Consultation Form | We need signed originals |