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Eric Tivers, LCSW, MSSW 224.636.3742 etivers@aol.com

Agreement for services Contract.pdf

Permission to Provide Therapy.pdf (Required for all clients under 18 years old)

Release of information.pdf (print one for each person you are authorizing Eric to communicate with, including teachers, grandparents, doctors, other therapists, etc)

electronic communications consent.pdf     

Intake.pdf

HIPAA Privacy Notice.pdf (Print or save for your records)

Acknowledgement of  HIPAA Notice.pdf

Credit Card Agreement.pdf

Downloadable Forms

Please fax or email completed forms to first visit.

Fax: 847.886.7251  email: etivers@aol.com