Forms

Please click on links to download and email completed forms to Debra@positivereframe.org

Only share information electronically if you feel safe to do so. I recommend ensuring your personal privacy settings on your electronic devices as well as using a virtual private network (VPN).

Feel free to call me at 847-603-4677 or email with any questions or concerns.

Therapy Disclosure Statement IL 2018

Intake Form

“Any minor 12 years of age or older may request and receive counseling services or psychotherapy on an outpatient basis without the consent of the minor’s parent or guardian. Outpatient counseling or psychotherapy provided to a minor under the age of 17 shall be limited to not more than 5 sessions, a session lasting not more than 45 minutes, until the consent of the minor’s parent or guardian is obtained.  The minor’s parents shall not be informed without the consent of the minor unless the facility director believes such disclosure is necessary.  The minor’s parent or guardian is not liable for the costs of the outpatient counseling or psychotherapy. “  Section 405 ILCS 5/ of Mental Health and Developmental Disabilities Code

Minor/Parent Consent Form

A release of Information 2018

If you are experiencing a mental health emergency, please call 911 or visit your local emergency room

Call 1-800-273-8255 https://suicidepreventionlifeline.org/

Text 741741 from anywhere in the USA https://www.crisistextline.org/

 

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

w

Connecting to %s