Skip to Main Content
  • My Cart
  • Central Illinois Central IL 888.924.3786
  • Madison and St. Clair Counties & Metro East IL Metro East IL 618.877.4420

Chestnut Health Systems

Main Navigation

  • Contact Us
  • Search
  • EBTx Center
    • Treatments and Research
      • Treatments
        • Adolescent Community Reinforcement Approach (A-CRA)
        • Assertive Continuing Care (ACC)
        • Community Reinforcement Approach (CRA)
      • Cultural and Gender Relevance
      • Homeless and Street-Living Youth
      • Young Adults (ages 18-25)
      • Juvenile Justice
      • Co-Occurring Disorders
      • Dissemination and Implementation
    • Training and Certification
    • EBTx Locations
    • Resources
    • Testimonials
  • About Us
    • Accreditation and Affiliations
    • Board of Directors
    • Executive Leadership
    • Mission, Vision & Values
    • News and Media
      • Chestnut In The News
      • Media Inquiries
    • Our Logo Story
    • Strategic Plan
    • Contact Us
  • How We Can Help
    • Addiction Treatment
      • For Adolescents
      • For Adults
      • Gambling
      • Learn the Facts: Addiction
      • Overdose Awareness
    • Mental Health
      • For Children and Youth
      • For Adults
      • Learn the Facts: Mental Health
    • Family Health Center
    • Credit Counseling
    • Housing
    • Prevention
      • Grundy and Will Counties
      • Logan and Mason Counties 
      • Madison and St. Clair Counties
      • McLean County
  • COVID-19 Vaccines
    • About the Vaccine
    • Get the COVID Vaccine for Free
    • Vaccine FAQ
  • Fees and Payment
    • Paperwork and Forms
  • Locations
  • Employment
  • Lighthouse Institute
    • Bookstore
      • Books
      • CDs
      • Curricula
      • GAIN (Global Appraisal of Individual Needs)
      • Manuals
      • Monographs
    • GAIN Coordinating Center
    • Illinois Addiction Studies Archive
    • Institutional Review Board
    • Research Projects
    • Research Scientists
    • Staff Publications
    • Financial Conflict of Interest Policy
  • LI Bookstore
  • Chestnut Family Health Center
    • Services
      • Medical Services
        • Primary Care
        • Psychiatry
        • Lab and Pharmacy
        • Medication Assisted Treatment
      • Behavioral Health
      • Health Care Coverage Enrollment
        • What We Offer
        • Important Links
    • Commitment and Approach to Care
    • For Patients
      • What is a Patient-Centered Medical Home
      • Making an Appointment
      • Payment
      • Paperwork and Forms
      • Online Patient Services
      • healow™ App
      • Your Medical Records/Information
    • Our Providers
    • Collaborators
    • What is a FQHC?
    • Data and Reports
  • Blog
  • 2021 Community Health Needs Assessment
  • Fees and Payment

Paperwork and Forms

  • Consent to Treat - Illinois
  • Consent to Treat - Missouri
  • Disclosure Authorization - Illinois
  • Disclosure Authorization - Missouri
  • Financial Intake Form
  • Financial Responsibility and Authorization
  • Patient Rights - Illinois
  • Patient Rights - Missouri
  • Privacy Practices - Illinois
  • Privacy Practices - Missouri
  • Statement of Illinois Law on Advance Directives and DNR Orders
  • Verification of Employment/Unemployment

Sign Up For Our Newsletter

x
Get
Help
Now

Get Help Now

Please fill out the contact us form or call 888.924.3786.

For Madison and St. Clair Counties and for the Metro East area, call 618.877.4420.

If you know someone who is in immediate risk of hurting themselves or others, call 911.

National Suicide Prevention Lifeline  1.800.273.8255 

 

x
Our
Locations
and Services
Fees and Payment
  • Paperwork and Forms
    © Chestnut Health Systems Inc. All Rights Reserved.
    • Privacy Statement
    • Terms of Use