Privacy and Forms

At the Chicago Childrens Clinic, protecting the confidentiality of our patients and their families is a very high priority.

Click Here to download a .pdf version of our Privacy Statement

If you would like information about your child to be sent to another clinician or agency; or would like us to have permission to obtain records about your child from another clinician or agency. 

Click Here to download a .pdf version of the Consent for Release of Information form.

Please fill out the information requested and fax it to us at:  Fax 312-867-1242

It is our policy to obtain written consent from parents before initiating therapy or assessment. The consent forms below describe our policies, as well as the procedures for a typical evaluation or psychotherapy case. In cases of divorce, unless a court order is provided stating that one parent has sole custody for mental health and medical decision-making, BOTH PARENTS must provide written consent for treatment. 

Click Here to download a .pdf version of the Assessment Consent Form.

Click Here to download a .pdf version of the Therapy Consent Form.

Click Here to download a .pdf version of the Speech Language Consent Form.

Please sign the form and Fax it to us at: Fax 312-867-1242

Feel free to call us at 312-587-1742, if you have any questions, or Email us using the contact form on this site.

The application is available for download in Portable Document Format (PDF). You will need Adobe Acrobat Reader® to view or print these files.

If Acrobat Reader is not already installed on your computer, click on the icon below for a free Download. Then follow the instructions to install the program.