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Jeffrey Ciolino LCPC

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Client Forms

Below are intake forms needed for all new clients.  Please feel free to download and complete prior to your first session.

Informed Consent

Informed Consent for TeleMentalHealth

Informed Consent/Disclosure Statement – Michigan

Informed Consent for Covid-19

HIPAA Illinois Notice Form

Release of Information

Credit Card Authorization

Good Faith Estimate

Contact Information

jeffreyciolino@gmail.com

773.905.9805

 

4003 N Broadway St. Ste 204

Chicago, IL 60613

 

Illinois Department of Financial & Professional Regulations

Florida Telehealth

Michigan Bureau of Professional Licensing

© 2022 Jeffrey Ciolino, MA, LCPC