
Susan M. Stasek, PsyD
Therapy for adults & couples
on the North Shore
847-732-6027
the calm after the storm
Envision Psychological Services
Forms to Read, Download, Complete and
Bring to Your First Appointment
Adult Information Intake Form ~
All the facts needed to provide the best care
Patient Data and Insurance Form ~
Everything needed to bill your insurance
Financial and Treatment Policies ~
Includes policies about paying for missed appointments,not billing, using insurance, late cancellations, etc
Informed Consent ~
Includes information about risks and benefits, emergencies, limits of confidentiality and duty to warm, release of information and disposition of client files, etc.