Contact US (847) 796-6400 - contactus@360wc.com

Patient Forms


Please review and electronically sign the New Patient Intake Form:

New Patient Intake Form


Please review and electronically sign the Authorization for Release of Mental Health Information Form:

Authorization for Release of Mental Health Information Form


Please review and electronically sign the Authorization for Automatic Credit Card Payment Form:

Authorization for Automatic Credit Card Payment Form


Please review and electronically sign the Tele-MentalHealth consent form:

Tele-MentalHealth Consent Form


Please review and electronically sign the Private Pay Agreement- LCSW, LCPC:

Private Pay Agreement-LCSW,LCPC


Please review and electronically sign the Private Pay Agreement- Psy.D:

Private Pay Agreement-Psy.D


Please download and complete the Intake/Child Developmental Questionnaire:

Intake/Child Developmental Questionnaire


Please review and electronically sign the Emergency Contact Waiver:

Emergency Contact Waiver


Please review and electronically sign the Patient Services Agreement, LCSW, LCPC:

Patient Services Agreement, LCSW, LCPC


Please review and electronically sign the Patient Services Agreement, Psy.D:

Patient Services Agreement, Psy.D


Please review and electronically sign the Intern-Patient Intake Packet:

Intern- Patient Intake Packet


Please review and electronically sign the Intern-Release Form:

Intern- Release and Permission to Record Sessions


Please review and electronically sign the Intern-Patient Agreement Form:

Intern- Patient Services Agreement