CCCW Forms

CCCW requires that all new clients complete 1) the Consent Form and 2) the Telepsychology Form for virtual services. Completion of forms is required for services to take place.

The Release Form is highly recommended for individuals who have been referred to our practice by a physician or care provider.

The HIPAA Form is a pdf made available to all our clients to inform you of your rights. Please take a moment to view document.

CCCW works to make the completion of forms easy for all clients. All forms are available below as well as via your client portal, Therapy Appointment. Please contact practice manager during office hours if you have any questions or concerns: 773-345-3495 ext. 0.

How to Fill Out Our Forms Online:

We recommend using a laptop or computer for best accessibility in completing forms.

Consent Form*

Telepsychology Form*

Sign & Submit

*Required

Release Form*

Sign & Submit

HIPAA Form

Access Form

*Highly Recommended

Self-Pay Consent

If you do not have insurance or your insurance cannot be accepted at CCCW, please complete a self-pay consent form. Rate will be determined by calling the office.

Sign & Submit

Referral Form

Referring physicians or care providers are welcome to complete the referral below. Once received, the CCCW admin will contact referred individual for scheduling.

Sign & Submit

Call: 773-345-3495

Toll-Free: 855-264-9355

Fax: 855-792-0240

CCCW Forms

How to Fill Out Our Forms Online:

We recommend using a laptop or computer for best accessibility in completing forms.

Consent Form*

Telepsychology Form*

*Required

*Required

Release Form*

HIPAA Form

*Highly Recommended

Self-Pay Consent

If you do not have insurance or your insurance cannot be accepted at CCCW, please complete a self-pay consent form. Rate will be determined by calling the office.

Referral Form

Referring physicians or care providers are welcome to complete the referral below. Once received, the CCCW admin will contact referred individual for scheduling.

Call 773-345-3495