Registration Forms for New Patients

Please download and complete one of the following forms and bring it with you to your first appointment:

New Patient Information Form — Adolescent or Child

(Please also complete this form if you are a young adult covered by your parents’ insurance)

New Patient Information Form — Adult

Release of Information

If you wish us to secure information from your former psychiatrist or clinician, send your records to another psychiatrist or clinician, or provide information to another party, please download and complete this form.

Release of Information — HIPAA Compliant

Notice of Privacy Practices

Educational & Psychological Services is required to give you this Notice of Privacy Practices to comply with the regulations established under federal law — the Health Insurance Portability and Accountability Act, or “HIPAA.” Educational & Psychological Services is committed to protecting your mental health information, including health information protected by HIPAA and other federal and state laws and using that information appropriately. As part of your registration as a new patient you will be asked to sign that you have been given an opportunity to read and/or receive a copy of this form.


© 2019 Educational & Psychological Services, Ltd.   •   847 N. Center Street, Naperville, Illinois 60563   •   ph (630) 527-6322   •   fax (630) 548-0982   •   Site By: Bradley & Company