J Shoshana & Associates

1016 W Jackson Blvd, Ste 203, Chicago, IL 60607
Phone 847.670.8544


I hereby consent to behavioral health assessment and treatment of by the providers at J Shoshana & Associates.

My completion of the form below confirms my understanding that this treatment may include assessment, counseling, psychotherapy, and other forms of behavioral health intervention conducted in accordance with commonly accepted practices and standards in the field of behavioral health. The outcome of treatment may depend on many variables beyond the control of the treating provider. Therefore, I understand that neither J Shoshana & Associates nor a treating provider, can guarantee any specific outcome that will result in my treatment or that or any minor family member. I also understand that any payment for these services, whether made by me or by a third party, is payment made for the J Shoshana & Associates provider’s time, experience and effort, and not for any specific outcome.

    Today's Date

    Today's Date

    Please Select the “Submit” Button Before Proceeding