Helpful Forms and Information

If you are wanting to set up a counseling appointment as a new patient, please click the link to fill out the following form. This form is web-based, so it is not necessary to print it out. Simply fill out all the information and then click 'Submit' at the bottom. The form will be encrypted and securely sent to our practice via encrypted email. 

PLEASE NOTE: This form is only used to request a counseling appointment. If you are interested in Neuropsychological Testing, please go here for more information on our referral process for that service. Any requests received via this form for neuropsychological testing will not be processed.

• Request for Counseling Services

The following forms are PDF forms that must but be printed and signed. These may be brought with you to your first appointment or faxed to the office at 217-546-3184.

• PSCI Notice of Privacy Practices (this is for your informational purposes only, and does not need to be returned to the office)
• PSCI Informed Consent for Treatment

If you would like your psychologist/counselor to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), please complete this form to authorize the release of psychotherapy information:

• Authorization to Disclose Information Form

Note: To download Adobe Acrobat Reader for free, click here .