Forms/Paperwork

All new patients need to complete an intake form prior to their first visit. Please follow the links below to PCPA's Adult and Child/Adolescent Intake forms. Forms can be received through e-mail (Please save the file to your device, edit and email to intake@pcpachicago.com), printed and delivered to your first appointment, or faxed to 847-686-0090. 

• Adult Patient Intake Form
• Child and Adolescent Patient Intake Form

If you are attending psychotherapy via telehealth, please complete the following consent form prior to your first in-person visit and email it back to intake@pcpachicago.com.  

•  PCPA Telepsychology Consent Form 

Prior to your first appointment, please kindly review PCPA's Privacy forms by following the link below: 

• ​HIPAA Notice Form - Protection of Privacy

If you would like for your therapist at PCPA to communicate on your behalf with your primary or specialty care physician, or another third party, please fill out the Release of Confidential Information Form below and bring to your next appointment.  

• Release of Confidential Information

If you are attending psychotherapy in person during the COVID-19 crisis, please complete the following consent form prior to your first in-person visit and email it back to intake@pcpachicago.com.  

• Informed Consent for resuming in-person sessions

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