Sue H. Bae, Ph.D. & Associates -
Forms

Informed Consent (DOC — 42 KB)
This form outlines our policies and practices. Please read it thoroughly prior to your first appointment.

This form also gathers basic contact information, including insurance. This is the form for child or adolescent clients.

This form gathers basic contact information, including insurance. This form is for adult clients.


This is a consent form that allows for communication to occur via email, text message, or any other non secure manner.

This form outlines Illinois' HIPAA Privacy Rights and Practices.  This packet is for clients to read through and keep for reference. At the end of the packet is a form to sign acknowledging receipt of this information.

Payment Information (DOC — 26 KB)
This form is for any payment that must be collected after the insurance is billed, or for any co-pays.

Website Builder provided by  Vistaprint