Welcome to my practice! On this page you will find the necessary forms to begin treatment as well as office locations and parking information. In order to maximize the session time, it is helpful for you to review and complete the New Client Forms beforehand and bring them with you to the first session.
NEW CLIENT FORMS
Client Information Form asks some preliminary questions and for your contact information. Please fill this out and bring it with you.
Consent Form orients you to my practice and payment policies, what therapy is about, the risks and benefits of psychological treatment, and confidentiality issues. It is important legally and ethically that you be informed of these issues before we start treatment. Please ask me any questions you still have at any of our sessions. Please print this out, sign it and bring it with you.
Credit Card Consent Form if you would like to pay for services via credit card, please bring this form with you to your first session.
HIPAA Notice of Privacy Practices informs you about your privacy rights as required by federal law. It provides important information about legal limits to your confidentiality as a psychotherapy client. Please review this carefully, but you do not need to print it out.
Please also bring your Blue Cross Blue Shield card (if you are using insurance) with you so that I may make a copy.
5412 N Clark Street, Chicago, IL 60640
PLEASE NOTE: Please use the intercom system at the front entrance and you will be buzzed in. The office is located on the second floor in the South Suites (turn left at the top of the stairs and go all the way to the end of the hall). There are several practitioners in the suite, and we all practice independently. You may wait for your appointment in the shared waiting area.
Parking/Transportation: The office is a 10-15 minute walk from the Red line Berwyn and Bryn Mawr stops and is accessible by several buses, including #22. There is metered street parking on Clark and surrounding streets.
FEES, INSURANCE, AND PAYMENT
I am a contracted provider for Blue Cross Blue Shield of PPO, including Blue Choice PPO, and am considered an Out of Network provider for other insurance companies. Often (but not always)clients can still receive benefits with an out of network provider. If you have BCBS HMO, you may or may not receive out of network benefits.
If you have out of network benefits that you would like to use, I can provide you with a receipt with all the necessary documentation to submit to your insurance company. Please contact your insurance company to see what your mental health benefits are and if you have a co-pay, coinsurance, or an unmet deductible. Please let me know if you need assistance with this.
Fees and co-pays are due at time of service. Payment can be made via cash, check, or credit card. if you would like to pay via credit card, please complete the credit card consent form and bring it with you to our first session.
When you make an appointment, the time is reserved for you. If you need to cancel or reschedule, please let me know 24 hours in advance. PLEASE NOTE: There is a $100 fee for any missed appointment or late cancellations.