IMG 8160admin iconForms can either be brought into first session or scanned and emailed to This email address is being protected from spambots. You need JavaScript enabled to view it.. Please also provide a photo of the front and back of your current insurance card. 

For new clients, please download the following forms and complete them before your first session:
Assessment
Informed Consent
Insurance Verification 
Notice of HIPAA
Credit Card Authorization Form
Explanation of Benefits - This information can be obtained by calling the benefits number on the back of your insurance card. This document will help us predict your expected out of pocket costs for therapy. (You can often request for this document to be sent directly to us, or you can forward it to us when it is sent to you.) 

For clients experiencing yoga therapy with Tessa:
Yoga Waiver

For clients who are attending groups only (Wholehearted Living, Yogalates, etc)
Face Sheet

Informed Consent
Notice of HIPAA
Credit Card Authorization Form
Physical Release and Waiver

For all clients, please print a copy of your rights to privacy for your personal records:
HIPAA

If there is anyone with whom we should communicate in order to provide the best collaborative care, please also download and complete this form:
Release of Information

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





info @ headhearttherapy.com | phone 773.892.1933 | fax 773.869.5385 | 3759 N. Ravenswood, Suite 133, Chicago IL 60613