Sue H. Bae, Ph.D. & Associates
Forms
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Informed Consent for Teletherapy 2020.doc (DOC — 44 KB)
This form outlines our policies and practices for teletherapy. Please read it thoroughly prior to your first teletherapy appointment.
Informed Consent 2020.doc
(DOC — 44 KB)
This form outlines our policies and practices. Please read it thoroughly prior to your first appointment.
Client Information Sheet (Child) 2018.doc (DOC — 55 KB)
This form also gathers basic contact information, including insurance. This form is for and adolescent clients.
Client Information Sheet (Adult) 2018.doc (DOC — 63 KB)
This form gathers basic contact information, including insurance. This form is for adult clients.
Authorization for Communication 2020.doc
(DOC — 28 KB)
This is a consent form that allows for communication to occur via email, text or any other manner.
Illinois HIPPA Privacy Notice Form 2020.doc (DOC — 48 KB)
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.
Visa_MC Authorization Form 2019 (DOC — 30 KB)
This form is for any payment that must be collected after the insurance is billed, or for any co-pays.
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Authorization for testing.doc
(DOC — 24 KB)
These two forms are for collecting payment information for psychological testing services only. If you are a therapy client, you do not need to complete these forms.