May 12 2008
Intake form (Best to use Mozilla Firefox Browser)
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:
Primary Insurance information:
Name:
Identification number:
Group number:
Customer service telephone number:
Claim address:
Secondary Insurance information:
Name:
Identification number:
Group number:
Customer service telephone number:
Claim address:
Why you are considering therapy right now?
What are your most important concerns?
If you had a magic wand, what would you wish for right now?
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
Same sex attractions
Sexual identity
Suicidal thoughts or attempts
Homicidal thoughts or attempts
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.
If this is for couples counseling, please use the following list to describe your strengths and weaknesses in the way you communicate:
Go to the structured writing exercises and explore other questions which may relate to you.
Go to the help for Chicago marriages (relationships) category and explore some of those posts for help in either understanding a problem or finding a solution.
What else would you like to say about yourself, family or other significant relationships?
Fees and Cancellation Policy
Counseling and Psychotherapy: $140 (average fee for 50 minute session)
Sliding scale fees available
Medicare fee: $36.50 (50 minute session)
I keep 4 hours each week available for lower fee clients who want to work with me, but do not have the financial resources.
I charge the regular fee for missed appointments or appointments cancelled without 24 hour notice.
Medicare
If you have Medicare, your out of pocket expense is about $36.50 per session. If you have Medicare, plus a supplemental insurance policy (often BCBS offers these policies), your total fee may be paid by insurance.
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.
I do charge for cancellations unless you can give me 24 hr notice.
I ask that you not use email for any appointment cancellation notice. Email is not reliable, so I may not get your cancellation message in a timely manner.
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. Please wait until I come to get you, as I may be meeting with another client.
Thank you for completing this and I look forward to working with you.
Your signature:
Date: