Please click on links to download and email completed forms to

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 and Consent to Treatment form IL 2020

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

Text 741741 from anywhere in the USA

Leave a Reply

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

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

Facebook photo

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

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.