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Private Insurance Forms

For all private insurance clients, prior to starting services with your child, we will need the following from you. You can read and fill out the forms here or download the PDF’s and return to

Document Library

1. Verification of Benefits Form

2. HIPAA Policies and Consent

3. Patient Service Agreement

4. Patient Payment Responsibility

5. History Intake Form

6. Consent for Release of Information

7. Teletherapy Consent Form

(for clients interested in teletherapy)

8. Waiver for Self Payment

(for clients not using insurance)

9. MD Script

We will need a physician’s referral prior to our initial evaluation. You can email it to, or have your pediatrician’s office fax it to 312-610-5655.