Adult Intake Form

Light on Anxiety  requires that all clients maintain a credit card on file to cover any balance due after your insurance benefits are applied. For clients who are uncomfortable leaving a credit card on file through our secure billing system, clients can pay at the time of the visit for all services received.

Here’s how it works:

1. We securely save your credit or debit card before or during your visit.

2. If in network, we work with your insurance plan to determine your payment amount for the visit.

3. We process the payment for you automatically and email you the receipt to the email address supplied on the intake form. 

Light on Anxiety values collaborative care and strives to incorporate all relevant health information into our treatment plan for you.  In an effort to best serve you, please provide the contact information for all health care providers you are currently seeing or have seen in the last 6 months.

By completing this form, I authorize Light on Anxiety CBT Treatment Center and all staff clinicians at Light on Anxiety to release to, obtain from, or exchange information pertaining to:  treatment summary, history/intake, diagnosis, psychological test results, psychiatric evaluation/medication history, dates of treatment attendance for the purpose of:
evaluation/assessment and/or coordinating treatment efforts. This document is valid for the time period that patient is under care of Light on Anxiety. In addition, I understand I have the right to refuse completing this form, and that I may revoke my consent at any time (except to the extent that the information has already been released).

Note: For child clients, this release of information allows for exchange of information between therapist and child client when necessary and appropriate. 

What can I expect from initial visit? 

The first 1-2 sessions are devoted to a comprehensive assessment of your concerns and the development of a treatment plan.  After the initial assessment is completed, the treatment plan will be reviewed and recommendations will be provided regarding which Light on Anxiety therapist will be the best fit based on clinical needs and scheduling requirements. Note: the therapist who conducts the initial assessment may not be the therapist who provides ongoing treatment, but all initial findings will be thoroughly discussed and reviewed with the assigned Light on Anxiety therapist.

What will treatment entail?

Treatment will include one or a combination of the following: individual therapy (which can include family members), referrals to a psychiatrist for medication evaluation, specialized exposure therapy or referrals to a physician for medical evaluation. Exposure therapy may occur on a weekly basis, or may be required on a more intensive basis when your difficulties are more severe. All therapy we offer is empirically supported and provided to you because it is the treatment determined to be the most effective in assisting you in overcoming anxiety or anxiety-related conditions.

What is expected of me?

We expect you to come prepared to work hard and play an active role in treatment.  We will serve as your anxiety coach and teach you the skills and provide you with the support to move forward in living a vital life.  But it is up to YOU to do the hard and transformative work of applying these new skills in your every day life.

How frequently will we meet?

A treatment plan will be customized to your needs and therefore, after the initial assessment, your therapist will be able to provide you with a recommendation for treatment intensity. A treatment plan will be customized to your needs and therefore, after the initial assessment, your therapist will be able to provide you with a recommendation for treatment intensity.

What if I am experiencing a clinical emergency?

If you are in a mental health emergency and require immediate assistance, please go to the nearest hospital emergency room and leave a voicemail message for your therapist to notify them of the emergency (312.508.3645).  If you believe that you need therapy that provides 24 hour crisis management, please discuss this with your therapist and they will help you find a referral to a program that can best meet your needs. 

What is your policy on electronic communication?

For communication between sessions, we only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement.  This means that email exchanges and text messages with the office should be limited to administrative matters.  This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that we cannot guarantee the confidentiality of any information communicated by email or text. Therefore, we will not discuss any clinical information by email or text and prefer that you do not either. Also, we do not regularly check  email or texts, nor do we respond immediately, so these methods should not be used if there is an emergency.

Treatment is most effective when clinical discussions occur at your regularly scheduled sessions.  But if an urgent issue arises, you should feel free to attempt to reach out to us by phone.  We will try to return your call within 24 hours except on weekends and holidays.  If you are unable to reach us and feel that you cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call.  If  we will be unavailalbe for extended time, we will provide you the name of a colleague to contact in my absence if necessary.

Do you accept insurance?

Currently, Light on Anxiety Treatment Center only contracts as an in network provider with Blue Cross Blue Shield of Illinois (BCBSIL) and Preferred Provider Organization (PPO). Your insurance will provide a quote of benefits, not a guarantee of payment.  While the filing of insurance claims is a courtesy we extend to our in network clients, all charges are your responsibility from the date services are rendered. Reimbursement varies depending upon the level of benefits that you and your employer have chosen. Your degree of coverage is a matter between you and your insurance company and/or your employer.  Light on Anxiety cannot guarantee that your insurance will cover my services.  You should verify with your carrier that it will be covered and to what extent.  You will be expected to pay all co-payments, deductibles, and for uncovered and ineligible services.  If your insurance company has not paid a claim within 20 days of submission, you accept full responsibility for payment in full for any outstanding balance. 

For clients looking to obtain reimbursement from other insurers, we are happy to submit an out of network claim on behalf of the client to facilitate reimbursement of out-of-network mental health claims.  

Your copay is due at the time of your session. If you do not know your copay amount at the time of session, your therapist will collect the industry standard copay amount of $20 at the time of session and our billing department will make any necesary adjustments upon receiving payment from BCBS.

Your insurance company may require us to contact them to discuss your treatment and progress. We are glad to respond to brief requests for information. In the event that extensive information or written reports are requested, Light on Anxiety staff will contact you to discuss the likely fees associated with providing these services. Insurance companies may have different levels of coverage. 

In addition, if your BCBS member ID begins with CTY we recommend you contact your insurance provider to determine if you need to obtain preauthorization prior to commencing treatment at Light on Anxiety.

For all other insurance plans, clients are responsible for paying Light on Anxiety directly and then Light on Anxiety can electronically submit a paid super bill on your behalf to facilitate obtaining out of network reimbursement.  If you are interested in having Light on Anxiety submit a superbill to your insurance company, please provide your insurance information.

Do you accept Medicare/Medicaid? 

Light on Anxiety Treatment Center is not a covered provider for Medicare or Medicaid.  Therefore you or your legal representative accept full responsibility for payment of all charges. Usual Medicare limits to charges and services do not apply. By choosing to work with Light on Anxiety, you acknowledge that you completely forego the use of these benefits for your treatment at this center and agree that neither you nor any representative will file any claims to Medicare or Medicaid, nor will you ask the provider to do so.  You acknowledge that you freely enter this contract with the knowledge of your right to obtain Medicare covered services from providers who have not opted out of Medicare, and understand that you are not compelled to enter into private contracts with providers who have not opted out of Medicare.        

How much will treatment cost?

Light on Anxiety strives to make treatment as short term and cost effective as possible.  Light on Anxiety therapists know that it is their job to get you back into your life as quickly as possible.  Our current fees for light on anxiety therapy services are:

Master Level Clinician: 

30 minute session: $90
45 minute session: $135
60 minute session: $180 

Ph.D Level Clinician: 

30 minute session: $130 
45 minute session: $195
60 minute session: $260
 

Add-on services:

Light on Anxiety staff are available for home visits and other out of office exposure based work, when clinically necessary as well as for report writing and other documentation requests.  These services are pro-rated in 15’ increments at the therapist’s hourly rate. Travel time to and from the office is included in the total charge.  Light on Anxiety staff are also available via email, text and phone, for between session assistance.   In addition, Light on Anxiety staff is available to consult with other providers and write reports.  These services will also be pro-rated in 15’ increments at the therapist’s hourly rate. These calls may, or may not, be covered by insurance. 
 

What is your cancellation policy?

A cancellation fee for the missed session is charged for cancellations with less than 24 hours notice. Charges for missed appointments are not covered by insurance and are your responsibility. 

Are there any limits to confidentiality?

The information you share in therapy is confidential and will not be disclosed without your written permission except when you may pose a danger to yourself or others or as required under Illinois and Federal law.  If we ever suspect you are at risk to harm yourself or others, we are required to report this to the Firearm Owners Identification (FOID) program.  If you disclose information related to suspected child or elder abuse, Light on Anxiety is obligated to report it.  If Light on Anxiety receives a court order signed by a judge to release your information, we are obligated to honor it.

Light on Anxiety Litigation Policy 

I agree that I am here for treatment and that I have been advised that if I need an expert witness in my case, I should hire someone specifically for that purpose.  I understand that my Light on Anxiety therapist will not serve as a witness in any type of litigation.

I agree to advise my attorney that Light on Anxiety will not become involved in any litigation. I agree that should I seek the Light on Anxiety's involvement in such litigation I will be responsible for Light on Anxiety's attorney fees in consulting an attorney to avoid involvement.

If ordered by the court to participate in the litigation, either in giving a deposition or testifying or if I voluntarily agree the following rules shall I apply:

1.  Fees for time involved in preparing a report(s) for LOA attorney or the court must be paid in advance before such report will be written. 

2.  The fee for LOA testimony or deposition must be for a 3 hour block of time at $900 for the three hours.  Any time exceeding the 3 hours including travel time, shall be billed at the rate of $400 per hour.  Fees must be paid at least one week in advance of the testimony being given.  If not paid in advance, LOA will not appear to give testimony.

3.  If the testimony date is cancelled or rescheduled with less than one business day’s notice, the fee will not be returned or will still be owed. Any further rescheduling will require the payment of  another 3 hour minimum fee. 

What can I expect from initial visit? 

The first 1-2 sessions are devoted to a comprehensive assessment of your concerns and the development of a treatment plan.  After the initial assessment is completed, the treatment plan will be reviewed and recommendations will be provided regarding which Light on Anxiety therapist will be the best fit based on clinical needs and scheduling requirements. Note: the therapist who conducts the initial assessment may not be the therapist who provides ongoing treatment, but all initial findings will be thoroughly discussed and reviewed with the assigned Light on Anxiety therapist.

What will treatment entail?

Treatment will include one or a combination of the following: individual therapy (which can include family members), referrals to a psychiatrist for medication evaluation, specialized exposure therapy or referrals to a physician for medical evaluation. Exposure therapy may occur on a weekly basis, or may be required on a more intensive basis when your difficulties are more severe. All therapy we offer is empirically supported and provided to you because it is the treatment determined to be the most effective in assisting you in overcoming anxiety or anxiety-related conditions.

What is expected of me?

We expect you to come prepared to work hard and play an active role in treatment.  We will serve as your anxiety coach and teach you the skills and provide you with the support to move forward in living a vital life.  But it is up to YOU to do the hard and transformative work of applying these new skills in your every day life.

How frequently will we meet?

A treatment plan will be customized to your needs and therefore, after the initial assessment, your therapist will be able to provide you with a recommendation for treatment intensity. A treatment plan will be customized to your needs and therefore, after the initial assessment, your therapist will be able to provide you with a recommendation for treatment intensity.

What if I am experiencing a clinical emergency?

If you are in a mental health emergency and require immediate assistance, please go to the nearest hospital emergency room and leave a voicemail message for your therapist to notify them of the emergency (312.508.3645).  If you believe that you need therapy that provides 24 hour crisis management, please discuss this with your therapist and they will help you find a referral to a program that can best meet your needs. 

What is your policy on electronic communication?

For communication between sessions, we only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement.  This means that email exchanges and text messages with the office should be limited to administrative matters.  This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that we cannot guarantee the confidentiality of any information communicated by email or text. Therefore, we will not discuss any clinical information by email or text and prefer that you do not either. Also, we do not regularly check  email or texts, nor do we respond immediately, so these methods should not be used if there is an emergency.

Treatment is most effective when clinical discussions occur at your regularly scheduled sessions.  But if an urgent issue arises, you should feel free to attempt to reach out to us by phone.  We will try to return your call within 24 hours except on weekends and holidays.  If you are unable to reach us and feel that you cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call.  If  we will be unavailalbe for extended time, we will provide you the name of a colleague to contact in my absence if necessary.

Do you accept insurance?

Currently, Light on Anxiety Treatment Center only contracts as an in network provider with Blue Cross Blue Shield of Illinois (BCBSIL) and Preferred Provider Organization (PPO). Your insurance will provide a quote of benefits, not a guarantee of payment.  While the filing of insurance claims is a courtesy we extend to our in network clients, all charges are your responsibility from the date services are rendered. Reimbursement varies depending upon the level of benefits that you and your employer have chosen. Your degree of coverage is a matter between you and your insurance company and/or your employer.  Light on Anxiety cannot guarantee that your insurance will cover my services.  You should verify with your carrier that it will be covered and to what extent.  You will be expected to pay all co-payments, deductibles, and for uncovered and ineligible services.  If your insurance company has not paid a claim within 20 days of submission, you accept full responsibility for payment in full for any outstanding balance. 

For clients looking to obtain reimbursement from other insurers, we are happy to submit an out of network claim on behalf of the client to facilitate reimbursement of out-of-network mental health claims.  

Your copay is due at the time of your session. If you do not know your copay amount at the time of session, your therapist will collect the industry standard copay amount of $20 at the time of session and our billing department will make any necesary adjustments upon receiving payment from BCBS.

Your insurance company may require us to contact them to discuss your treatment and progress. We are glad to respond to brief requests for information. In the event that extensive information or written reports are requested, Light on Anxiety staff will contact you to discuss the likely fees associated with providing these services. Insurance companies may have different levels of coverage. 

In addition, if your BCBS member ID begins with CTY we recommend you contact your insurance provider to determine if you need to obtain preauthorization prior to commencing treatment at Light on Anxiety.

For all other insurance plans, clients are responsible for paying Light on Anxiety directly and then Light on Anxiety can electronically submit a paid super bill on your behalf to facilitate obtaining out of network reimbursement.  If you are interested in having Light on Anxiety submit a superbill to your insurance company, please provide your insurance information.

Do you accept Medicare/Medicaid? 

Light on Anxiety Treatment Center is not a covered provider for Medicare or Medicaid.  Therefore you or your legal representative accept full responsibility for payment of all charges. Usual Medicare limits to charges and services do not apply. By choosing to work with Light on Anxiety, you acknowledge that you completely forego the use of these benefits for your treatment at this center and agree that neither you nor any representative will file any claims to Medicare or Medicaid, nor will you ask the provider to do so.  You acknowledge that you freely enter this contract with the knowledge of your right to obtain Medicare covered services from providers who have not opted out of Medicare, and understand that you are not compelled to enter into private contracts with providers who have not opted out of Medicare.        

How much will treatment cost?

Light on Anxiety strives to make treatment as short term and cost effective as possible.  Light on Anxiety therapists know that it is their job to get you back into your life as quickly as possible.  Our current fees for light on anxiety therapy services are:

Master Level Clinician: 

30 minute session: $90
45 minute session: $135
60 minute session: $180 

Ph.D Level Clinician: 

30 minute session: $130 
45 minute session: $195
60 minute session: $260
 

Add-on services:

Light on Anxiety staff are available for home visits and other out of office exposure based work, when clinically necessary as well as for report writing and other documentation requests.  These services are pro-rated in 15’ increments at the therapist’s hourly rate. Travel time to and from the office is included in the total charge.  Light on Anxiety staff are also available via email, text and phone, for between session assistance.   In addition, Light on Anxiety staff is available to consult with other providers and write reports.  These services will also be pro-rated in 15’ increments at the therapist’s hourly rate. These calls may, or may not, be covered by insurance. 
 

What is your cancellation policy?

A cancellation fee for the missed session is charged for cancellations with less than 24 hours notice.  Charges for missed appointments are not covered by insurance and are your responsibility. 

Are there any limits to confidentiality?

The information you share in therapy is confidential and will not be disclosed without your written permission except when you may pose a danger to yourself or others or as required under Illinois and Federal law.  If we ever suspect you are at risk to harm yourself or others, we are required to report this to the Firearm Owners Identification (FOID) program.  If you disclose information related to suspected child or elder abuse, Light on Anxiety is obligated to report it.  If Light on Anxiety receives a court order signed by a judge to release your information, we are obligated to honor it.

Light on Anxiety Litigation Policy 

I agree that I am here for treatment and that I have been advised that if I need an expert witness in my case, I should hire someone specifically for that purpose.  I understand that my Light on Anxiety therapist will not serve as a witness in any type of litigation.

I agree to advise my attorney that Light on Anxiety will not become involved in any litigation. I agree that should I seek the Light on Anxiety's involvement in such litigation I will be responsible for Light on Anxiety's attorney fees in consulting an attorney to avoid involvement.

If ordered by the court to participate in the litigation, either in giving a deposition or testifying or if I voluntarily agree the following rules shall I apply:

1.  Fees for time involved in preparing a report(s) for LOA attorney or the court must be paid in advance before such report will be written. 

2.  The fee for LOA testimony or deposition must be for a 3 hour block of time at $900 for the three hours.  Any time exceeding the 3 hours including travel time, shall be billed at the rate of $400 per hour.  Fees must be paid at least one week in advance of the testimony being given.  If not paid in advance, LOA will not appear to give testimony.

3.  If the testimony date is cancelled or rescheduled with less than one business day’s notice, the fee will not be returned or will still be owed. Any further rescheduling will require the payment of  another 3 hour minimum fee. 

Please answer the following based on the past 2 weeks.