Patient Forms

New patients are required to fill out several forms before therapy can begin. To make the process as smooth and efficient as possible, we provide the most important documents as downloads right here on our website. 

 

Please download, complete and bring the following forms to your first scheduled session:

  • Patient Registration Form
  • Informed Consent for Psychotherapy for Your Therapist
  • Notice of Privacy Practices
  • Notice of Privacy Practices Consent Form
  • Financial Policy

If you are unsure which forms to fill out, don't hesitate to contact us.

 

For your convenience, we also provide the additional forms as downloads:

  • Authorization to Release Confidential Information
  • Agreement for Parents
  • Feedback Questionnaire

Intake/Initial Session Forms

Patient Registration Form
PSC Registration Form.pdf
Adobe Acrobat document [272.7 KB]
Informed Consent Dr. Bautista
PSC Informed Consent Updated.pdf
Adobe Acrobat document [161.1 KB]
Notice of Privacy Practices
PSC NPP.pdf
Adobe Acrobat document [370.9 KB]
Notice of Privacy Practices Consent Form
PSC Consent to Privacy Practices.pdf
Adobe Acrobat document [356.0 KB]
Financial Policy
PSC Updated Financial Policy 2016.pdf
Adobe Acrobat document [96.3 KB]

Additional Forms

Authorization to Release Confidential Information
PSC Authorization to Release Confidentia[...]
Adobe Acrobat document [93.1 KB]
Agreement for Parents
PSC Agreement for Parents.pdf
Adobe Acrobat document [377.0 KB]
Feedback Questionnaire
PSC Feedback Questionnaire.pdf
Adobe Acrobat document [380.0 KB]

Note: You will need Adobe(r) Reader(r) to view PDF files. If you do not have it, you can download it for free.

Where to Find Us:

1300 W. Belmont Ave.

Suite 304

Chicago, IL 60657

Office Hours

Monday:        12:30 p.m. - 9:00 p.m.

Tuesday:       12:30 p.m. - 9:00 p.m.

Wednesday:   12:30 p.m. - 9:00 p.m.

Thursday:      12:30 p.m. - 9:00 p.m.

Friday:           11:00 a.m. - 7:00 p.m.

Saturday:      9:00 a.m. - 3:00 p.m.

Sunday:          9:00 a.m.- 3:00 p.m.

 

If you are unable to keep your appointment, please cancel your scheduled appointment at least 24 hours in advance.

Patient Forms

New patient? Save time and reduce the amount of paperwork you have to fill out at your first visit. We provide several patient forms as PDF downloads on our site. Please click on the Forms tab in the left hand column above.