Client Intake Forms

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 email or simply bring them with you to your·first appointment.

Not all forms are required of everyone. You can complete using the following guideline or schedule for what applies to you:

FIRST SESSION

The following for in office, in person sessions
Required for new clients to return BEFORE or AT the 1st session (Click to Open):

  1. New Patient Info form 11/19  #2
  2. Agreement for services 2/20  #5
  3. Release of Info 8/20 #6
  4. Stress Symptom Checklist 3/09  #8
  5. Enlarged copy of both sides of ins ID card

Also REQUIRED for telepsych/video/online sessions, ADD the following (Click to Open):

  1. Consent for Telepsych sessions 6/20 #4
  2. Credit Card Agreement 8/15/20 #31

2  Optional for any new cls who are seeking one of the following services (Click to Open):

  1. Request for Disability Eval Agreement 8/20 #27
  2. Request for Medication Eval Agreement  8/20 #29
  3. Request for Bariatric Eval Agreement 5/20 #28
  4. Credit Card Agreement 8/15/20  #31

SECOND SESSION
1 Required for new clients BEFORE or AT the 2nd session- whether in-office or telepsych sessions (Click to Open):

  1. General Background form 11/19  #7 (for each adult)
  2. Client Treatment Expectations 6/20 #9
  3. Picture ID (driver’s lic copy, etc)

OPTIONAL FORMS AFTER 2ND  or 3RD SESSION -whether in-office or telepsych sessions (Click to Open):

  1. Agreement to charges for missed appts 8/20  #20
  2. Client Permissions form 11/19 #12
  3. Family Stress  Checklist 3/09 #17
  4. Credit Card Agreement 8/15/20  #31

INSURANCE ID CARDS:

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.