Forms

All Clients

Please print, fill out and/or sign the following forms:

 Client Data

 Basic Information Acknowledgement

 Privacy Policy

 Electronic Communication Agreement


Insurance

If you will be using insurance, please print and fill out the following form:

 Release of Information for Insurance Billing


Additional Provider Release

If you have another provider you would like to give us permission to communicate with, please print and fill out the following form:

 Release of Information


Intake Forms - Kate Evans

If you will be seeing Kate Evans, please print the following questionnaires that apply to you:


For Your Records

The following forms are for you to keep for your records:

 Notice of Privacy Practices

 Basic Information and Treatment Agreement

 Electronic Communication Agreement

Let's Connect

Contact us to see if we may be a good fit.

If this is a medical emergency, please call 911.

We highly respect and safeguard your privacy and will never disclose your email address and message to anyone. You acknowledge that the contents of this form will be sent via email and will be stored on servers located in the United States, and understand that you should not use it to provide any personal health information.



Our Office

103 N 11th Avenue, Suite 101
Saint Charles, IL 60174