Adult Intake Form | Meghan Litwiller


Meghan Litwiller, MSW
Access Counseling Services, Inc.
175 Olde Half Day Road, Suite 140-9, Lincolnshire IL 60069
19 N. County Street, Waukegan IL 60085
(815) 627-0479 | meghan@jdanielsphd.com
jdanielsphd.com

 

Referral Source:   Date:  

 

Client Information (Adult)

Name:  

Home Address:  

City:    State:    Zip Code:  

Home Phone:   

Work Phone: 

Cell Phone:

VM & Text Approval:

E-Mail Address:

Birth Date: 

Gender: Age:  



 

Emergency Contact Information

Emergency Contact:

Relationship to You:

Phone Number:  

Payment

Financial Guarantor:

 

- or-  

 

Relationship to You:

-or-  

 

Mailing Address:

-or-  

 

Phone Number (s):

-or-

 

Medical Information
 

Psychiatrist:   

Psychiatrist Phone:

Primary Care MD: 

Primary Care MD Phone:

Therapy Type:

Reason for Therapy:


Employment
 

Occupation:

Employer:


Insurance

Primary Insurance Company:

Group Number:

Policy Number :

Policy Holder's Name:

Policy Holder's Social Security:

Self-Pay, No Insurance to be used:

 

FINANCIAL ASSIGNMENT AND RELEASE OF INFORMATION AUTHORIZATION

As the client (and/or legal guardian and/or financial guarantor), I certify that I have active and valid insurance as stated above and authorize payment directly to Jennifer Daniels, PhD, LCPC as indicated on insurance submittal forms or as otherwise agreed upon.  I also authorize Jennifer Daniels, PhD, LCPC exchange private healthcare information with insurance company (ies) required to verify insurance benefits, obtain treatment authorizations process insurance claims and/or engage in collection process.  I grant permission for my (and/or my legal guardian’s) signature to be used in place of this original signature for all insurance transactions.

In the event that insurance does not cover claims, whether in part or wholly, or if I am not covered by insurance, I understand that I (or person financially responsible) am liable for all incurred charges.  Full-payment and/or co-pays and/or deductibles, as applicable, are to be rendered at time of service, unless other financial arrangements have been agreed upon between therapist and client and/or financial guarantor.

 

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Document name: Adult Intake Form | Meghan Litwiller
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Timestamp Audit
March 8, 2023 12:03 am CSTAdult Intake Form | Meghan Litwiller Uploaded by Jennifer Daniels - jennifer@jdanielsphd.com IP 72.207.59.93
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