New Patient FormsFor your convenience, you may download the new patient forms to save you time before your first appointment. If you are unable to fill out this paperwork beforehand, please plan to arrive 15 minutes prior to your scheduled appointment time.
Please be advised that while you should fill out either the adult or child history form based on who the patient is, you will need all other forms listed here. Client Information Adult History Child/Adolescent History Payment Policy Psychotherapist-Patient Services Agreement If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information: Release Form Note: To download Adobe Acrobat Reader for free, click here. A Word About Insurance: Whether to use your insurance is something you should carefully consider. While it may save you money, it comes at the cost of your privacy. It may also cost you money in the long run. At minimum, insurance companies require a mental illness diagnosis, the procedure provided, and information that identifies both you and your policy. Some insurance companies require treatment summaries or even session progress notes, especially if they dispute a charge. Once your insurance company has this information, neither you nor we can control where else it goes. For example, insurance companies will likely add this information to a national database. After that, any time you apply for other health insurance (not provided by an employer), this has the potential to affect your premium cost. The same applies for life (and other) insurance. Additionally, you could be denied life insurance coverage all together, on the basis of this information. There are other potential ways in which this information may be used against you that may be difficult to foresee. If you would like to avoid your diagnosis and treatment information going elsewhere, the only way to accomplish this is to pay for treatment yourself. Fortunately, a revision to HIPAA law entitles you to do just that. If you choose, you may sign a waiver to avoid sending such information. To do this, the law requires you to pay your entire bill in full. On the other hand, paying for therapy yourself may be an undue burden for some people. In this case, using health insurance to pay for coverage can be preferable to not receiving treatment at all. If you would like to use your insurance benefit, we strongly encourage you to verify your coverage information. You should know your coverage levels for both in and out of network providers. You should also ask what your annual deductible (the amount you pay before your insurance company starts to pay some of the costs) is. You should find out what your copay (flat dollar amount per session) or coinsurance (a percentage of the session fee) costs are. In addition, you should find out whether out of pocket maximums (OOPM) apply, and how much this would be. OOPM refers to how much you pay per year before the company picks up the entire cost of services. Please note that there may be separate deductibles, differing amounts the company pays per session, and/or OOPM for out of network services. We will check patient benefits, staff time permitting. We are in-network with Blue Cross Blue Shield PPO. Currently, we also submit bills on your behalf. If we receive payment directly, we will apply the information to your bill, once received. Our office will always do our best to communicate with you about the status of your account and any changes with your coverage. Please do not hesitate to contact us at 630-717-7771 if you have any questions or concerns. We appreciate your confidence in us, and can't wait to meet you! |
Providing help for children, teens, adults, couples, & families in the areas of anger management and stress relief, anxiety disorders, depression, couples and marriage counseling, family counseling, special needs, alcohol abuse, addiction & recovery.
With our office in Naperville, Integrative Counseling & Psychological Services, PC (ICAPS) serves the areas of Downers Grove, Aurora, Des Plaines, Bolingbrook, West Chicago, Plainfield, Woodridge, Westmont, Lisle, Warrenville, Fox Valley, Darien, Winfield, North Aurora, & the surrounding Illinois communities.
With our office in Naperville, Integrative Counseling & Psychological Services, PC (ICAPS) serves the areas of Downers Grove, Aurora, Des Plaines, Bolingbrook, West Chicago, Plainfield, Woodridge, Westmont, Lisle, Warrenville, Fox Valley, Darien, Winfield, North Aurora, & the surrounding Illinois communities.