Minor Intake Form
Jennifer Daniels PhD, LCPCAccess Counseling Services, Inc.175 Olde Half Day Road, Suite 140-9, Lincolnshire IL 6006919 N. County Street Waukegan IL 60085(224)225-9650 | firstname.lastname@example.org
Name (minor/under 18):
Minor's Parent/Legal Guardian:
City: State: Zip Code:
Home Phone: N/A
Work Phone: N/A
Cell Phone: N/A
VM & Text Approval:
E-Mail Address: N/A
Minor Birth Date:
Relationship to Minor: Parent Step-Parent Legal Guardian
Relationship to You:
Phone Number (s):
Primary Care MD: N/A
Primary Care MD Phone:
Therapy Type: Individual Couple Family Group
Reason for Therapy:
Primary Insurance Company:
Policy Number :
Policy Holder's Name:
Policy Holder's Social Security:
Self-Pay, No Insurance to be used: yes no
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)
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Minor Intake Form
Agree & Sign