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


Minor Intake


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:




Financial Guarantor:


Relationship to You:


Mailing Address:


Phone Number (s):



Medical Information:


Psychiatrist Phone:

Primary Care MD:   

Primary Care MD Phone:

Therapy Type:

Reason for Therapy:


Primary Insurance Company:

Group Number:

Policy Number :

Policy Holder's Name:

Policy Holder's Social Security:

Self-Pay, No Insurance to be used:





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:

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Signature Certificate
Document name: Minor Intake Form | Carolynn Brusseau
lock iconUnique Document ID: e790be403c7435bcab226aa05fff1eb3afe686fa
Timestamp Audit
May 9, 2023 11:40 pm CDTMinor Intake Form | Carolynn Brusseau Uploaded by Jennifer Daniels - jennifer@jdanielsphd.com IP