The Psychology Center, Inc
(A Professional Corporation)

10343 S Western Avenue
(near 103rd Street)

Chicago, IL  60643

General Office Telephone (24 hours) 773/238-2828

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New Client Intake Forms

NEW CLIENTS "INTAKE" FORMS - (can be completed ahead of time for your convenience)

If you are going to be a new client at The Psychology Center, Inc· and you have already scheduled your first appointment, you may find it convenient to print out a copy of the following "new client forms" and complete them at home ahead of time - before your first visit. Then you can mail the completed forms to us, or fax them to our confidential fax #708-974-3845- or simply bring them with you to your·first appointment.


REQUIRED FORMS for first session:

  1  New Patient Information form (NPI form)

2  Agreement for Services form

REQUIRED FORMS for second session:

1  General Background Information form (one for each adult or older teen attending)

2   Stress Symptom Checklist (one for each person attending)

3  Supervision / Co-Therapy Agreement form

OPTIONAL FORMS to be completed anytime you wish:
            1  Your Treatment Expectations
            2  Survey of Potential Sources of Family Stress


     To reduce your costs as much as possible, it is very important that you bring your insurance plan ID card(s) with you for us to enlarge and photocopy (both sides), OR you can send them to us ahead of time to help us determine your coverage benefits, co-pays, etc.  (Enlarge and photocopy both sides so the information comes out clearly).  If your insurance plan sent you a letter or treatment authorization form, bring that with you too for us to copy.

     The Psychology Center, Inc is in-network with just about every health insurance plan there is, so we will work with your plan to get you the lowest cost possible for your visits.  Most clients pay LESS THAN $30 co-pay per visit, but this may vary according to the plan you have selected.  Your co-payments should be made at each session.


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Last modified: 06/15/19