NewClient

New Client Form

If you are a new client please fill out the form below. The form below will NOT actually schedule you a session and is only the paperwork needed for an initial session.
How did you hear about us? *
Who referred
Name or place of who referred you
Your Information
Name *

First Name Last Name
Gender *
Date of Birth *

- Month - Day Year
E-mail
Phone Number *

- Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Billing Information
Should we bill Insurance, EAP, or Self-Pay? *
Insurance/EAP
ID Number
Group Number
Insurance Phone
Provider or Customer Service
Authorization Number
If Applicable (EAP required)

Consent for Treatment

Consent that you can be seen by Lake Cook Behavioral Health
1. I hereby consent to receive behavioral health services through Lake Cook Behavioral
Health as provided by psychotherapists, psychiatrists or other menthal health professionals of Lake-Cook Behavioral Health.

2. I authorize and request that Lake Cook Behavioral Health and my physician(s) perform assessments, administer treatments and medications, and obtain laboratory evaluations as may be considered advisable in the diagnosis and treatment of my condition.

3. I realize that no particular outcome/result can be guaranteed as a result of my consent to treatment at lake-Cook Behavioral Health.

4. I hereby release my psychiatrist, psychologist, social worker, counselor and Lake-Cook
Behavioral Health Resources and their employees from responsibility for any injury which
results from my leaving Lake-Cook Behavioral Health services against clinical
and medical advice.

5. Your treatment is confidential within the limits prescribed by law. In general, no
information about your treatment will be released without your written consent. However,
relevant laws require that your therapist contact others about your safety if you present a
danger to yourself or to others. If your therapist learns of child abuse or neglect, or if
ordered by a court.

In addition, your therapist may consult with other therapists within Lake Cook Behavioral
Health to improve the quality of your treatment. Your therapist may release
information about you to an insurance company or managed care company if you are
using these benefits.

If you (client) are younger that 12 years of age, your therapist may discuss your treatment with your parent or legal guardian. If you are older than 12 years of age and younger than 18 years of age, your therapist may discuss your treatment with your parent or legal guardian with your consent. If you are engaging in behavior that your therapist believes places you in danger of significantly harming yourself or others, your therapist will help you to discuss these issues with your parents.

6. I agree that I will provide 24-hour notice to cancel a scheduled appointment. If I do not
give proper notification, I understand I am responsible for the full session fee (insurance
cannot be billed for a late cancellation or a failed appointment).

This consent form has been fully explained to me and I certify that I understand and agree with its contents.
Name. *
Date

- Month - Day Year
Signature *

Release of Information for Processing Benefits

You give us permission to send information to your insurance/EAP for billing purposes
I hereby authorize Lake-Cook Behavioral Health Resources to release any of the following
requested information for the purpose of obtaining reimbursement/payment for treatment services provided directly to me or my dependents. Information may include:
1. Diagnosis
2. Designated clinical records, e.g., treatment
3. Discharge summary plans, progress notes, laboratory results, etc.

Information may be released to any or all of the following as needed:
1. Any third-party payor having responsibility for payment of charges for treatment
2. Review agents/auditors
3. Managed care/utilization review agents

This consent is valid until such time that all claims have been settled to the satisfaction of LakeCook Behavioral Health or up to one year from the date of discharge from Lake Cook
Behavioral Health, whichever is longer.

I understand that in some cases, I and/or my dependents may be receiving services for which I am not the insured or for which there is more than one insured. In this case, I authorize Lake Cook Behavioral Health to contact the actual or additional insured (e.g., my spouse) and to share information necessary to obtain reimbursement for services.

I understand that I may revoke this consent at any time and that I may inspect and copy the information to be disclosed. I further understand that I can invalidate this consent any time before the expiration date so long as I submit revocation in writing to the address listed below. Finally, the agency reviewing the clinical information and/or records will be advised not to disclose my records to any other agency/person without my written informed consent.

I understand that I am ultimately responsible for any and all charges not paid for by my medical insurance, and that if I refuse to sign this Release of Information, I will likely have to pay for any and all charges incurred.

I certify that I am the client and that I have received a copy of this form. If I am not the client, I certify that I am adult authorized as the client’s general agent to execute the above and accept its terms.

ASSIGNMENT OF BENEFITS: In consideration of services to be provided to me or to my
dependent, I hereby assign, transfer and set over to Lake-Cook Behavioral Health Resources, all of my rights, title and interest to reimbursement benefits under my insurance policy(ies), including any and all major medical benefits. I understand I am financially responsible to Lake Cook Behavioral Health for charges not covered by this assignment.
Name
Today's Date

- Month - Day Year
Confirm Signature

Instructions For Handling Confidential Information
If We Call By Phone:

Lake Cook staff may identify themselves by phone. For example “This is Jane Jones from Lake Cook Behavioral Health.” Lake Cook staff may leave a message containing identifying information on your cell phone. Lake Cook staff may leave a message containing identifying information with household members or on your home answering device regarding business matters or appointment scheduling. Lake Cook staff may leave a message containing identifying information on your work voicemail.
Billing E-mail
Should be Empty:

New Client Form

Your Information

Billing Information

Consent for Treatment

Release of Information for Processing Benefits

Instructions For Handling Confidential Information