Home
About Me
Services
Getting Started
Resources
- Physical Health Links
- Mental Health Links
Contact Me

312-971-9340 ext 101
tonikogan@gmail.com

Toni Kogan Counseling

Get in Touch CONTACT

Authorization for Release of Information

July 13, 2015 by TNKGN2718 Leave a Comment

Authorization for Release of Information

Toni Kogan, MA, LCPC, CADC

17 North State Street Suite 1723
Chicago, Illinois 60604

312-971-9340 ext 101
tonikogan@gmail.com

Send a Message

Your Name (required)

Your Email (required)

Phone

Your Message

Terms of Use*

Yes, I want to submit this form

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.

Please leave this field empty.

Δ

All Rights Reserved

A Bright Site by Brighter Vision
Privacy Policy

Copyright © 2025 · Genesis Child on Genesis Framework · WordPress · Log in