Initial Assessment Forms & General Forms
Initial Assessment Forms
Blank forms will be available in the waiting room but please arrive at least 20 minutes before your appointment to give yourself enough time to complete them.
If you would like to complete the forms before our first appointment you can either print them out and complete them by hand or fill them out online and print them out to bring with you.
Visit the Email Forms Instructions Page if you would like instructions on how to complete the forms online and email them to me. Unfortunately completing forms online does not work on the Firefox browser or mobile devices but printing and completing by hand does.
The following forms need to be completed before our first session – the Initial Assessment Form, the Patient Information Sheet and the HIPAA Privacy Information & Confidentiality Form. Depending on your symptoms, you may also like to complete the mood inventories below. If you wish to pay by credit card and/ or want me to submit a claim to your insurance on your behalf, please also complete those forms.
Please complete all these forms.
Depending on your symptoms you may wish to complete these forms.
Using Medical Insurance Benefits
If you would like me to submit your insurance claim to your insurance company on your behalf please download the Insurance Submission form below.
Credit Card Payment Authorization
If you would like to authorize session payments using your credit or debit card, please download the form below and fax the completed form to 847 562-9352.
Consent To Communicate With Your Other Healthcare Providers
Please complete the Consent to Release Information Form below if you would like me to be able to communicate or release information regarding your therapy to other doctors or for disability records.
Weekly Unhelpful Thought Diaries
An important part of Cognitive Therapy is keeping track of unhelpful thoughts (also called cognitions). Together we will look at where theses types of thoughts come from, how they are holding us back and how to reframe them in a way that improves mood. The Thought Diary can be downloaded below and gives a structured way to identify unhelpful negative thoughts. Side 2 gives a list of questions that help us challenge these unhelpful negative thoughts.