Call 815-397-4287 to schedule
FORMS
COMPLETE AND READ
Please take a moment to download, print and complete each form.
Remember to bring your completed forms, photo ID and insurance card (if applicable) to your first appointment. If you forget or are unable to print the forms, they are available in the office. There will be a clipboard on one of the chairs in the waiting room with copies of the forms. Please plan to arrive 20-30 minutes before your appointment if you plan to complete the forms at the office.
Form asking for basic info such as name, address, phone number, emergency contact, etc.
Outlines our policy regarding confidentiality, billing insurance plans, missed appointments, and more...
If you would like us to bill your insurance directly, complete this form.
Complete this form if you would like a someone such as your spouse, parent, psychiatrist, or physician to receive or provide us with your medical records.
READ
Please review the following information before your initial appointment.
Copies are also available at the office.
CHANGE OF INFORMATION
You are currently working with a counselor but the information we have on file is no longer correct.
Click on the asterix to obtain the required form. Then simply print and complete and either bring it in to your next appointment, mail or email it. Whatever is easiest for you.
MOVED - NEW ADDRESS
Complete, sign and date the Patient Demographic Form. You can also update your emergency contact.
INSURANCE
New Insurance Policy, insurance member number or group number changed, add a secondary policy
Complete, sign and date the Insurance Form
You would like your provider to disclose or received medical information to a particular individual.