FORMS

 

Prior to your first visit, please review, print out, and complete the attached forms.  Completeting and bringing the forms to your first visit allows Melinda to focus on getting to know your goals and hopes for counseling during the first session.

 

INTAKE FORMS (Choose the most appropriate form for who will be receiving services from Melinda.)

 

  • If you are the parent of a teenager, please complete the "Child Intake" form and ask your teenager to complete the "Teen Intake" form separately

  • If you are coming for couples counseling, please have each partner complete a separate "Adult Intake" form

 

 

 

 

 

 

 

 

 

POLICY PRACTICES (Complete one Statement of Practice Policies form)

 

 

 

 

 

 

PRIVACY PRACTICE (HIPPA) DISCLOSURE (Please read the Notice of Privacy Practice and complete one Acknowledgement form)

 

 

 

 

 

 

 

CONSENT FOR RELEASE OF PROTECTED HEALTH INFORMATION (Complete one form for each person you are giving consent for Melinda to contact.)

 

 

 

 

© 2020 Melinda Gronen Counseling and Consulting, LLC

Call me:

847-227-9624

Find me: 

10 W Phillip Road, Suite 124

Vernon Hills, IL 60061