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.
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?
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 your taking right now:
Describe any concerns you have related to 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. Be detailed beginning with early use.
Also, go to alcohol screening.org, complete the survey, add your score here:
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.
Fees and Cancellation Policy
Counseling and Psychotherapy: $75-90 (average fee for 50 minute session)
Blue Cross Blue Shield PPO fee is $75. Client is responsible for copayment and annual deductible, unless already met.
Medicare fee: $36.50 (50 minute session)
I charge the regular fee for missed appointments or appointments cancelled without 24 hour notice.
Telephone and Email
My business phone number is 312-409-0632. This is the number I ask you to call with any appointment related questions.
Email, texting, or messages left on my work cell phone are not accepted ways to cancel or reschedule appointments.
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, a 4 number code 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.
Your signature:
Date:
