Chicago and Oak Brook Psychologist Office forms

Please download, print and complete form and bring completed form to your scheduled appointment

Demographic Information Form

This form gives us needed information prior to your first visit. It tells us how to contact you, what insurance information to use, and other relevant information to help you best.

office forms

Client Feedback Form

This form gives us permission to disclose information about your treatment for treatment, payment and healthcare operations. Your information is confidential, we will only disclose information to those you have given us written permission to disclose information, or under a court order, or to protect you or others from imminent harm.

office forms

Authorization To Release Confidential Information

This form gives up permission to release confidential information to any person or agency of your choosing. This may include family, referral networks, other healthcare providers, friends, employers or others whom you designate. We will only release information to those you have given us written consent to disclose confidential information to, unless ordered by a court or in emergency or to protect from imminent harm.

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HIPPA Notice Of Privacy Practices

This form acknowledges you have received a copy of our privacy statements. You must bring this form to our office with other forms.

office forms

Fee and Cancellation Policy

This describes our fees and business practices and your obligation to pay for services rendered. It also provides information about cancellation policies for your scheduled appointments.

office forms

Adult Assessment Form

This form gives us information that you provide about yourself. It lets us know of your concerns, problems and the nature of what has brought you to our office. This form is for adult patients to complete prior to the first visit.

office forms

Child Assessment Form

This form gives us information that you provide about your child. It lets us know of your concerns, problems and the nature of what has brought you to our office. This form is for parents  to complete prior to a child’s the first visit.

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Informed Consent

This is a statement of services that may be provided, limits of treatment, and how you can participate in your own treatment planning. It gives us permission to work with you, and describes our professional relationship.

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Marital Diagnostic Interview

This should be completed before your first session, it will help Dr. Khan to work with you and your partner in effective ways.