Oakbrook Psychotherapists

Problems of Childhood & Adolescence
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Feedback Informed Therapy
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CLIENT FORMS

 
 
 

Required Forms

 
 

Client Fact Sheet
Client Application
Financial Policy
Insurance Benefit Form
Service Agreement - Signature Page
HIPAA Privacy Notice - Signature Page
Physician Release Form
Adult Information Form

Child Information Form
Release to Insurance

 
   
 
 
 

HIPAA and Service Agreement

 
 

HIPAA Privacy Notice
Service Agreement
Service Agreement Appendixes

 
   
 
 
 

FIT Rating Scales

Adult Version 11
Adolescent Version 11
Child Version 11

 
   
 
 
 

Optional Forms

 
 

School Release Form
Release of Information
Multiple Attendees Form
Adolescent Confidentiality Form
Special Parental Consent Forms

 
   
   
  • To the right, in the top box, are the Required Forms for the first appointment.
  • Please print out each form separately.
  • Each form needs to be completed and brought to the first session
  • For the HIPAA and Service Agreement we only need you to provide us with a copy of the signature page (for each form). However, please read these documents carefully prior to your appointment.
  • When you come to the first session please bring a copy of your insurance card.
  • Please complete and sign the Physician Release Form so we can coordinate care with your doctor (while this is not required, most insurance companies request that we coordinate care with your physician).
  • Please complete the Adult or Child Information Form.
  • Please sign Release to Insurance form, so we can share information with your insurance company, when necessary.

HIPAA PRIVACY NOTICE & SERVICE AGREEMENT

  • The HIPPA Privacy Notice and Service Agreement (including Appendixes) are very important documents.
  • The HIPAA Privacy Notice explains guidelines for confidentiality.
  • The Service Agreement and Appendixes detail Centers for Family Change’s policies.
  • Please read these forms prior to your first appointment.
  • If you have any questions be, sure to raise them with your therapist.
  • Please complete the Adult or Child Information Form
  • Please sign Release to Insurance form, so we can share information with your insurance company, when necessary.

FEEDBACK INFORMED THERAPY FORMS

  • In the box titled FIT, are the Feedback scales for the first appointment.
  • Please print out and complete the appropriate scales for you and your family.

For individual adults the Adult Version 11
For teenagers the Adolescent Version 11 (ages 12-17) (parents and teens should complete)
For children the Child Version 11 (parents and children -if old enough - should complete)
For couples both members of the couple should complete the Adult version 11

  • For children and adolescents be sure to indicate who is completing the scale: the Child/Adolescent or an Adult who knows the child/adolescent well.
  • Be sure to blacken the circle for each answer.
  • Please skip the bottom three items (they are not used for the first session).

OPTIONAL FORMS

  • Please complete the School Release Form if the client is a student and you would like your therapist to talk to school personnel.
  • Please complete the Release of Information form to allow us to obtain records from previous therapists (be sure to list the clinician’s name and phone number).
  • Complete the Multiple Attendees form if you are likely to involve your spouse or partner in your therapy sessions.
  • Complete the Adolescent Confidentiality Form if the client is a child, 12-17, who is likely to have individual sessions.
  • Please review and sign the appropriate forms included in Special Parental Consent Forms, if there are concerns about the consent of both parents for the treatment of a child.
  • If you have questions about any of these forms you can discuss them with your therapist at the first appointment.

PAYMENT INFORMATION

Payment is required at the time of service. For the first session the fee is $175.00 and for following sessions the fee is $150.00. However, if you are using your insurance your fee will most likely be discounted. Please discuss this with your therapist.

Your Centers for Family Change therapist accepts cash or checks. We expect payment at time of service for co-pays, co-insurance and/or deductibles. We will bill your insurance for their portion of the fee.

PAYING BY CREDIT CARD

You can now pay your Centers for Family Change bill by credit card (currently only available in our Oakbrook office). Please talk with your therapist about how you can utilize this option.




Copyright©2017. Centers for Family Change. All Rights Reserved. Sitemap |
2625 Butterfield Road, Suite 101N, Oakbrook IL 60523
Phone: 630-586-0900 | Fax: 630-586-9990

 

Oakbook Psychotherapy