See us in three locations
Sycamore | Rochelle | Elgin

815.787.9000 | 815.561.8855| 847-717-7347

Hours Of Operation

9 a.m. to 6 p.m.
After hours by appointment only

Forms

Evaluations


ADHD

Authorization to Release Protected Health Information
Client Information
Fees, Rights, Consent, and Confidentiality

Alcohol and Drug Evaluations

Authorization to Release Protected Health Information
Client Information
Fees, Rights, Consent, and Confidentiality

Anger

Authorization to Release Protected Health Information
Client Information
Fees, Rights, Consent, and Confidentiality

DUI

DUI Evaluation Packet
DHS Informed Consent

You must print the DHS Informed Consent document and bring it in.

Pain Managment

Authorization to Release Protected Health Information
Client Information
Fees, Rights, Consent, and Confidentiality

Partner Abuse Intervention Program

Authorization to Release Protected Health Information
PAIP Intake
Program Rules

SOS

Authorization to Release Protected Health Information
Client Information
Fees, Rights, Consent, and Confidentiality

Family, Couples and Individuals


Family and Couples

Authorization to Release Protected Health Information*
Client Information
Fees, Rights, Consent, and Confidentiality

* Must have a copy for each person.

Individuals

Authorization to Release Protected Health Information*
Client Information
Fees, Rights, Consent, and Confidentiality

Income


Income List

Programs


C.A.L.M.

C.A.L.M. Intake Packet

SOAR

SOAR Authorization to Release Protected Health Information
SOAR Fees, Consent, Confidentiality and Patient Rights
Program Rules
SOAR Intake Form
SOAR Rules

Substance Abuse Treatment


Continuing Care

Continuing Care IIS Fax, Mail in Form
Continuing Care Level III Call In Form
Continuing Care Level III Fax Mail in Form
Continuing Care Level IIS Call in Form

DUI Evalutaion

DUI evaluation leaflet to keep
DUI evalution information

Intake

Level III Intake Packet
Level IIM Intake Packet
Level IIS Intake Packet
Level IM Intake Packet

Additional Forms

Authorization to Release Protected Health Information
Fees, Rights, Consent, and Confidentiality
Intake Form
Medical Intake Screening