(847) 910-2077

pbutlerlmft@yahoo.com

Client Forms

If you are new, please feel free to fill out these intake forms before our first session. These forms can also be filled out during the first session.

Client Intake Form

Information Sheet

Limits of Confidentiality

If you feel that you would like to collaborate your session with another provider, simply fill out the following form.

Authorization for Release of Information

 

Contact Today

(847) 910-2077
pbutlerlmft@yahoo.com

Oak Brook

1010 Jorie Blvd
Suite 102
Oak Brook, IL 60523

Arlington Heights

415 W Golf Rd
Suite 4
Arlington Heights, IL 60005

Have Questions…
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By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

For the health, safety, and well-being of our clients & providers, we have suspended all in-person appointments. In the meantime, all current and future appointments are available through secure video or on the phone.
We look forward to continuing to provide excellent care and service to our clients during this challenging time