Location
1751 South Naperville Road.
Suite 207
Wheaton. IL 60189
Phone
(630) 774 8316 | (630) 674 1138
Fax
(630) 690-3353
Email
info@theselfempowermentcenter.com

   
 
Please complete all applicable forms prior to your first session as it will save you time.

Demographic Information Form

HIPAA Notice of privacy practices

Consent to use or disclose information for treatment, payment, and health care operations (TPO)

Authorization to Release Information

Fee and cancellation policy

Adult Mental Health Assessment

Child and Adolescent Mental Health Assessment

Marriage Interview Form

Insurance Authorization Verification Form


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