Insurance & Forms

Insurance

I am an in-network provider for Blue Cross/Blue Shield PPO of Illinois and Medicare. If you are using one of these plans, I will check your benefits for you and submit claims to your insurance. Your co-payment is due at the time of service. Please check whether you have met your annual deductible before you schedule your first appointment if you plan to use your insurance benefits. If you have not met your deductible, you will be responsible for payments at the insurance contracted rate until you have met your deductible.

If you would like to use other insurance, I am happy to serve as an out-of-network provider if your plan allows for this. You will need to pay the full fee at the time of service and I will give you a receipt which you can then submit to your insurance company for reimbursement.

Forms

For our first meeting, you will need to complete the Intake Form, and read the Psychotherapy Agreement and Privacy Policy (HIPAA). You may print out these forms by clicking on the links below. I will go over the Agreement and Privacy Policy with you during our meeting, and obtain the required signatures. Please bring the completed Intake Form with you to our appointment. You are welcome to email me the completed Intake form, but I cannot guarantee the confidentiality of email communications (see "Privacy Policy" tab), so if you choose to communicate confidential information via email, I will assume that you have made an informed decision and will view it as your agreement to take the risk that your email may be intercepted.

Intake Form

Psychotherapy Agreement

YOUR CART

Insurance & Forms.