Alternative Counseling Center, LLC
INTAKE INFORMATION

PATIENT’S NAME_________________________________________________________
                                      FIRST                    INITIAL                                 LAST
PARENTS OF MINOR_______________________________________________________

ADDRESS__________________________CITY___________STATE_____ZIP_________

HOME PHONE________________	 PATIENT’S BIRTH DAY____________

INSURANCE INFORMATION

INSURED’S NAME AND ADDRESS___________________________________________
SS#_________________________ INSURANCE COMPANY_______________________
ADDRESS_________________________________________________________________
GROUP NO. ______________________ INSURED’S EMPLOYER___________________
WORK NO. ______________________ REFERRAL SOURCE_______________________

CONSENT FOR TREATMENT OF CHILDREN AND ADOLESCENTS: I/We consent that 
__________________ may be treated as a client or clients by Lisa Terwilleger LIMHP, LPC

Signature(s) ___________________________________ Date_________________________

CONFIDENTIALITY AND EMERGENCY SITUATIONS: Your verbal communication and clinical records are strictly confidential except for: a) information shared with our staff psychiatrist and b) information you and your child or children report about physical or sexual abuse; then, by Illinois State Law, I am obligated to report this information to the Illinois Department of Children and Family Services, c) information shared with your insurance company to process your claims, d) where you sign a release to have specific information shared, e) if you provide information that informs me that you are in danger of harming yourself or others.  If an emergency arises for which the client or their guardian feels immediate attention is necessary, the client or the guardian understands they are to contact the emergency services in the community for those services.  Lisa Terwilleger LIMHP, LPC will follow those emergency services with standard counseling and support to the client or the client’s family.

Signature(s) ___________________________________Date________________________

Financial/insurance issues: As a courtesy, we will bill your insurance company, HMO or responsible party if you wish.  We ask that at each session you pay your co-pay. In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied.  If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time as we do minimal billing practices.  In the event that an account is overdue and turned over to our collection agency, the client or responsible party will be held responsible for any collection fee charged to our office to collect the debt owed.  Lastly, we ask that every client authorize payment of medical benefits directly to Alternative Counseling Center, LLC.  We sincerely appreciate your cooperation and at any time you have any questions regarding insurance, fees, or payments, please feel free to ask.

Signature(s)______________________________ Date_________________________