Intake

Intake form

 

Complete these questions prior to our first session if possible. If this is for couples therapy, each person should complete this form.

 

Please note that you it is best to access this form via the Mozilla Firefox browser (click here for free download) and then can copy and paste this form into a Word document. Use as much space as you need.

 

If for couples therapy, please fill out separate form both partners:

 

Name:

 

Address:

 

Phone:  home               cell               work

 

Email address:

 

Birthdate:

 

Insurance information:

 

Insurance Company:

 

Name:

 

Identification number:

 

Group number:

 

Customer service telephone number:

 

Claim address:

 

What are your most important concerns?

 

If this is for couples therapy, what are the major issues to focus on right away?

 

Do you often get into escalating fights?

 

Have you ever utilized therapy before? What was your experience?

 

Have you used anti-depressant medication or other medications before? Please specify what, when and dosage.

 

Identify any medications and dosage you’re taking right now:

 

Describe any concerns you have related to each of the following:

 

Thinking/concentration

 

Ability to focus

 

Complete tasks

 

Rapid heart beat

 

Panic attacks

 

Fears

 

Sleep

 

Eating

 

Anxiety

 

Depression

 

Low self-esteem

 

Sexual relations

 

Sexual orientation

 

Thoughts of self or harm to others

 

If you use alcohol or other drugs, describe your current and historical frequency (how much/how often) use.  Please describe your routine use of alcohol, marijauna and any other drugs.

 

Also, go to alcohol screening.org, complete the survey, add your score here:

 

How much time do you spend on your computer/internet?

 

Do you spend time with significant others (spouse/partner/family/friends) ?

 

What are the activities you enjoy?

 

Do you share household responsibilities like cleaning, shopping, childcare, etc with your spouse/partner?

 

Do you think you are a better listener or speaker?

 

Describe the family in which you were raised:

 

What were the major concerns in your family?

 

Who were you emotionally close to and emotionally separate from? Why?

 

How was the communication in your family?

 

Describe any times in your life where you felt mistreated or abused in any way both within your family and outside of your family. Start from when you first remember until the present time.

 

What else do you think I should know about you?

 

Scheduling

There are only two ways to make or cancel appointments with me:

  1. Telephone:  312-409-0632
  2. Online scheduling system: Click here.

I do not accept cancellations by email or text messaging.

 

I  only accept messages about appointments or other matters at my 24 hour voice mail phone number: 312-409-0632.

I am not available 24 hours, 7 days a week, so if you have an urgent matter or crisis, it is important for you to go to the nearest emergency room, rather than contacting me.

If you need to speak with me, please call my 312-409-0632 voice mail number and I will get back to you as soon as possible. I listen to messages on this system all day long and should be able to get back to you within a short time.

Email and text messaging are the most unreliable ways to reach me…please call me at 312-409-0632 if I have not gotten back to you within 24 hrs.

 

Fees

 

My fees range between $90 and $150 depending on insurance and ability to pay. I am a PPO provider for BCBS, Aetna, Cigna and Medicare.

 

 

Insurance Eligibility

 

I ask that all clients  contact their  insurance provider to determine benefits and eligibility and provide me with the following information.

I have written questions for you to follow to help obtain this information:

 

What is my annual deductible?                      .

 

When does my deductible begin?                      .

 

How much of my deductible has been met this year?                 .

 

What is my co-payment?                   .

 

What is my calendar year annual session limit?                     .

 

Cancellation Policy

 

I charge the regular fee for missed appointments or appointments cancelled without 24 hour notice.

 

No fee will be charged for illness, accident or emergency. Working late is not acceptable.

 

INITIAL HERE____I understand Bill only accepts cancellations through the online scheduling program or by calling the 312-409-0632 voicemail number.

 

Telephone and Email

 

My business phone number is 312-409-0632. I often use my work cell phone to return calls, but I ask you to call me back on my work phone number above to expedite me getting back to you.

 

Email, texting, or messages left on my work cell phone are not accepted ways to leave messages, cancel or reschedule appointments.

 

INITIAL HERE____I give understand email is not a secure way to communicate and give permission to Bill to email me at this email address:                                                          .

 

Parking

 

There is a parking lot on the west side of the building for use after 5:30pm and on weekends. Ample street parking is also available, except during Cubs baseball games, so please keep this in mind and read parking signs to avoid ticketing.

 

Entry to the building

 

After 5pm Monday through Friday and on weekends, the code 3971 is needed for entry. When using this code, remember to enter only the 4 numbers I give you. Do not enter any # or * signs as this will not activate the door opener.

 

Waiting Room

 

There is a small waiting room area for your convenience on my floor near my office.

 

Thank you for completing this and I look forward to working with you.

 

In signing this form, you are giving me permission to file insurance claims for services rendered and acknowledging you understand my policies and procedures and have had the opportunity to ask any questions for clarification.

 

Your signature:

 

Date:

 

Your signature:

 

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