If you wish to complete new client paperwork prior to your visit, you may obtain the forms below and bring to your visit.  If you prefer, you may come to the office a few minutes prior to your visit to complete the paperwork in the waiting area. Feel free to leave any blanks where you have questions or contact us if something is unclear. A copy of the Privacy Practices is available upon request or can be printed from the website.

Initial Forms

Intake Paperwork: These forms are required for all clients and can be accessed by clicking the button below.

Telehealth Forms

Telehealth Client Office Policies and Consent Form: Any client participating in telehealth must complete this form and have it on file at our office prior to engaging in a telehealth visit.  New clients who are having their first appointment via telehealth should complete this telehealth consent form and the initial paperwork above.  Existing clients who have already completed intake paperwork only need to complete the telehealth policies and consent form.  

Once complete, email to info@radzomcounseling.com, securely fax to 618-248-2040, or mail to PO Box 101; Edwardsville, IL 62025.  The form must be received and processed prior to your therapist being able to conduct a telehealth visit.  Forms are generally processed on weekdays during business hours; please submit them to our office early to allow processing time.  

Ongoing Forms

Authorization to Use and Disclose Information: If you wish to grant permission to your provider to consult with or release information to an individual or entity outside of the group, this form needs to be completed in order to give proper consent to your counselor to release confidential information.

Autopay Enrollment: To have your monthly statement balance automatically charged to your credit or debit card, complete the autopay enrollment form.  Once complete, securely fax to 618-248-2040 or mail to PO Box 101; Edwardsville, IL 62025.

Notice of Privacy Practices: We take privacy extremely seriously.  Read our notice below to learn the details.