Minor Intake Form | Carolynn Brusseau




Carolynn Brusseau, MA, LPC
Access Counseling Services, Inc.
175 Olde Half Day Road, Suite 140-9, Lincolnshire IL 60069
19 N. County Street, Waukegan IL 60085
carolynn@jdanielsphd.com | 312-600-5367
jdanielsphd.com

 

Minor Intake

Date:

Referral Source:  

Name (minor/under 18):  

Minor's Parent/Legal Guardian:  

Home Address:  

City:      State:   Zip Code:  

Home Phone:

Work Phone:

Cell Phone:

VM & Text Approval:

E-Mail Address:

Minor Birth Date:

Gender: Age:  

 

Emergency Contact Information

Emergency Contact:  

Relationship to Minor:

Phone:  

 

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:
 


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.

I (and/or my legal guardian and/or financial guarantor) also understand that insurance coverage is
determined at time claim is processed by insurance carrier.  As such, insurance carrier (s) and/or provider
cannot guarantee coverage. 

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.


Minor's Signature/Consent (Type full name)

Parent/Guardian's Initials 

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Minor Intake Form | Carolynn Brusseau
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May 9, 2023 11:40 pm CSTMinor Intake Form | Carolynn Brusseau Uploaded by Jennifer Daniels - jennifer@jdanielsphd.com IP 72.207.59.93
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