📋 Printable New Patient Forms

New patients should use TheraNest whenever possible. These printable forms are available if you have trouble using the portal.

🔒 Do not email completed forms — bring them to the office
Questions?  Our team is happy to help before your first visit.
📞 Call (847) 516-2538 📅 New Patients — Use TheraNest ✉️ Send a Message

If You Cannot Use TheraNest

✍️
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.
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TheraNest is our preferred intake option. New patients can create an account, view availability, and complete assigned forms securely online. Get started in TheraNest →

Download All Forms at Once

One PDF with all required forms, provided as an alternate option when TheraNest is unavailable or difficult to use.

⬇ 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 Complete Packet
🩺
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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