Adult Intake Form Light On Anxiety Adult Intake Form Step 1 of 8 12% Helpful Tip Before You Start1. Our form is most compatible with Google Chrome. If you would like to pause when working through the form, please use the save and continue link at the bottom of the page. 2. If you would like support or assistance in filling out Light On Anxiety's intake form or if you would like to schedule a time for a care manager to fill out this form with you, contact [email protected] and we would be happy to assist you with this process. 3. PLEASE NOTE: the time and effort you put into filling out this intake form serves as the initial building block to your treatment plan. All information will be reviewed by your intake therapist prior to your 1st session so we can assist you in moving past obstacles you and your family are experiencing as rapidly as possible. What are your treatment goals at Light On Anxiety?*Are you currently experiencing suicidal thoughts?* Yes No Consent*If you are currently experiencing active suicidal thoughts, please obtain care at your nearest emergency room. You deserve immediate support to assist you in moving past this challenging moment. Light On Anxiety provides outpatient therapy and is therefore not the appropriate provider to support you in managing the distress you are currently experiencing. You will get through this difficult time, but you deserve the right level of support and assistance to ease your emotional distress. For immediate assistance: National Suicide Prevention Lifeline: Call 1-800-273-8255 Crisis Textline: Text HOME to 741741 NAMI Chicago: Call 833-626-4244 I understand Light on Anxiety not an appropriate mental health provider if I am currently experiencing a mental health emergency.Have you ever attempted suicide?* Yes No Please provide brief background information such as date of attempt, means and treatment received.*Do you have a history of violent behavior, such as getting into physical altercations?* Yes No Please explain your history of violent behavior, such as getting into physical altercations.*Light On Anxiety Clinical Specialty Policy* Light On Anxiety specializes in CBT & ERP based treatment for children, adolescents and adults, as well as family based interventions, with a focus on anxiety, OCD and other related mental health conditions. Light on Anxiety is not an appropriate treatment provider if you are seeking assistance with the following conditions: - Substance Related and Addictive Disorders - Self Harm - Suicidal Ideation - Homicidal Ideation - Anorexia, Bulimia or Other Eating Disorders - Bipolar and Related Disorders - Disruptive, Impulse-Control and Conduct Disorders - Schizophrenia Spectrum and Other Psychotic Disorders - Therapy ordered by the court as a result of litigation I understand Light On Anxiety's clinical specialty policy and acknowledge I am seeking treatment for anxiety or a related condition. I also understand Light On Anxiety is not an appropriate mental health provider if I am currently experiencing a mental health emergency. If it is determined during intake session or at any point upon initiating treatment at Light On Anxiety your clinical needs will be more appropriately met by an external care partner, Light On Anxiety is available to offer your therapeutic care coordination services to help you get set up and begin receiving services with a mental health provider that best meets your clinical needs and can most effectively move you past the challenges you are experiencing.Patient Legal Name* First Last Patient Preferred Name Preferred PronounsPronouns are used to refer to someone in the third person. We want to know how to respectfully refer to you. Examples: he, him, his she, her, hers they, them, theirs Patient Date of Birth* Month Day Year Patient Email Address* Phone*What is your preferred method of communication?* Email Phone Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Current licensure laws require clients to be physically located in the state of Illinois while receiving teletherapy.* I certify that I will be physically located in the state of Illinois during my sessions. Release of Information for Emergency ContactAs the individual receiving Cognitive Behavioral Therapy (CBT) at Light On Anxiety or Parent or Guardian of Recipient or other person entitled to inspect and copy Recipient’s records pursuant to 740 ILCS 110/4 or, as applicable 42 CFR 2.31 and/or 20 ILCS 301/1-1), I hereby authorize Light On Anxiety to disclose and/or obtain information from my mental health records to the following party (please provide name and contact information for party):Name of Emergency Contact for LOA to Exchange Information With* Emergency Contact Email Address* Emergency Contact Phone*Emergency Contact Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country The purpose of this disclosure is for the following:*Care when there is concern for the client's safetyOther (please specify below)Other (please specify): The specific nature of the information to be disclosed is as follows:* Any information related to securing the safety of the client Other (please specify below) Other (please specify): Advanced Consent to Release Information* I hereby acknowledge and agree to Advanced Consent of the release of information detailed in the prior question.Acknowledgement of right to inspect all information disclosed:* I understand and acknowledge that I have the right to inspect and copy any and all information such being disclosed pursuant to this Consent.Acknowledgement of potential consequences of a refusal to consent to release of records:* I understand and acknowledge potential consequences of a refusal to consent to release of records, for example, Light on Anxiety no longer providing therapy or if a third party (not an insurance company) requires these records to pay for therapy, a consequence may be that the therapy will not be paid for.Acknowledgement of Right to Revoke Consent* I understand and acknowledge that I have the right to revoke this Consent at any time. I further understand that any Revocation of this Consent shall be in writing, signed by me or the person who gave the Consent and the signature on the Revocation of the Consent shall be witnessed by a person who can attest to my identity or the identity of the person who signed this Consent and is entitled to sign the Revocation of this Consent. I further understand that no Revocation of this Consent is effective to prevent disclosures of records and communications until it is received by Light On Anxiety. The Revocation of this Consent shall have no effect on disclosures made prior to receipt by Light On Anxiety of the Revocation of Consent.Re-disclosure of Information* I have been made aware that no information disclosed by Light On Anxiety may be redisclosed without my specific consent to redisclose.Copy of Consent Will Be Stored in Patient Record* I understand and acknowledge that a copy of this Consent and a notation as to any action taken thereon shall be entered in my record.This Advanced Consent will expire on the date below:*Note: It is recommended to select a date one year from today. MM slash DD slash YYYY Name of Signee (Recipient of Services at Light On Anxiety or Parent or Guardian of Recipient of Services at Light On Anxiety)* Signature of Recipient or Parent or Guardian of Recipient or other person entitled to inspect and copy Recipient’s records pursuant to 740 ILCS 110/4 (and/or 42 C.F.R. 2.31).*Date Consent Signed On:* MM slash DD slash YYYY Witness attestation to signing of this consent (note: if you do have a witness currently available, contact [email protected] and we are happy to serve as your witness):* I hereby attest to the identity and that I witnessed the individual receiving Cognitive Behavioral Therapy (CBT) at Light On Anxiety or Parent or Guardian of Recipient or other person entitled to inspect and copy Recipient’s records sign this Consent for the Disclosure of Mental Health Records and Communications.Name of Witness to Signing of This Consent* Signature of Witness to Signing of this Consent*Date Consent Signed On* MM slash DD slash YYYY Is Light On Anxiety currently treating any other members of your immediate family?* No Yes Please review and consent to Light On Anxiety's policy regarding treating multiple family members*Light On Anxiety is happy to be of assistance to multiple members within a family. Unless a release of information is signed, information will not be shared between Light On Anxiety therapists. Also, if ever it becomes unhelpful for Light On Anxiety to be seeing multiple family members, Light On Anxiety will provide the appropriate external referrals and assist with a care transition plan. I agree to this policy.How did you hear about Light On Anxiety?* Physician / Healthcare Provider Health Insurance Google Light on Anxiety Event Article or Media Appearance Book Authored by Dr. Kissen Facebook Twitter Pinterest Friend School Contact Other If other, please indicate:* Name of Referring Provider* Referring Provider Organization (if applicable) Phone Number of Referring ProviderEmail Address for Referring Provider: Would you like to sign up for the Light On Anxiety newsletter, to stay informed about anxiety relieving tips and tools?* Yes No Payment Authorization FormThis form provides important information regarding billing procedures and payment policies at Light On Anxiety. If you have any questions, please contact us at (312) 508-3645 or [email protected] prior to signing this form. Insurance-Based Services Light On Anxiety is an in-network provider with Blue Cross Blue Shield of Illinois (BCBSIL) Preferred Provider Organization (PPO), Blue Choice PPO and Aetna. 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. If your insurance company has not paid a claim within twenty (20) days of submission, you accept full responsibility for payment in full for any outstanding balance. It is recommended that you contact your insurance company prior to beginning treatment at Light On Anxiety in order to review your specific benefits including preauthorization requirements and your copay and deductible amounts. For all other insurance plans, clients are responsible for paying Light On Anxiety directly. We are happy to submit claims electronically, on a monthly basis, to facilitate obtaining out of network payment. We recommend contacting your insurance company to learn about your out of network benefits. Private Pay Rates All clients not utilizing in-network insurance have the right to receive a "Good Faith Estimate". Private pay rates for clients not utilizing in-network insurance benefits are below. Master Level Clinician: Intake and treatment planning sessions (first two sessions): $180 each ($360 total) 25 minute sessions: $90 40 minute sessions: $135 55 minute sessions: $180 Doctorate Level Therapists: Intake and treatment planning sessions (first two sessions): $260 each ($520 total) 25 minute sessions: $130 40 minute sessions: $195 55 minute sessions: $260 Cancellation Policy All appointments cancelled with less than 24 hours notice are subject to a cancellation fee. Charges for missed appointments are not covered by insurance and are your responsibility. Coordination of Care Light On Anxiety values collaborative care with other providers as it helps to create the most integrated and appropriate treatment plan. If you are currently taking psychotropic medications, Light On Anxiety requires a 20 minute collaborative care meeting with the medication prescriber at the start of treatment. If you are using insurance benefits for Light On Anxiety services, we will attempt to obtain reimbursement for this collaborative care service from your insurance company. If the insurance company does not provide reimbursement, you will be charged at a prorated private pay rate. We attempt to keep all collaborative care exchanges as quick and effective as possible, typically about 20 minutes. Collaborative care will be billed at a prorated rate based on the time spent. Twenty (20) minutes of collaborative care will be billed at a rate of $70.Is the patient the individual responsible for billing?* Yes No Name of individual responsible for billing*Note: By providing this information to Light On Anxiety you authorize communication with individual financially responsible for your services for billing and administrative information exchanges. Email address for individual responsible for billing* Phone number for individual responsible for billing*Will you be using health insurance benefits to access Light On Anxiety services?*Light On Anxiety is in-network with BCBS PPO, Blue Choice PPO and Aetna. Light On Anxiety can also assist you in submitting to your out-of-network insurance provider for possible reimbursement. Yes No Insurance Plan*Light On Anxiety is in network with BCBS PPO, Blue Choice PPO and Aetna. BCBS PPO Blue Choice PPO Aetna Other (please specify below) Insurance Plan Is the patient listed above the primary insured?* Yes No Name of primary insured* Relationship* Self Spouse Parent Other Address for primary insured* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of birth for primary insured* Month Day Year Insurance Claim Submission Requirement* I acknowledge that If I do not upload a picture of the front and back of my insurance card, I will instead email a copy of my insurance card to [email protected] or I will be charged at Light on Anxiety’s private pay rates. Please upload a picture of the FRONT of your insurance card.Note: If you are unable to attach a file, please email a photo of both the front and back of your insurance card to [email protected] Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.Please upload a picture of the BACK of your insurance card.Max. file size: 64 MB.Member ID (Please be sure to include letter pre-fix to number, "X" or "XXX")* Group Number* Credit Card on File 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 may pay Light On Anxiety's private pay rate via cash or check at the time of session for all services received. In the event that reimbursement is received from the insurance company, the client will be refunded any overpayment. Here's how it works: 1. We securely save your credit or debit card before 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.Credit Card Type* Visa Mastercard Discover American Express Name on Credit Card* Credit Card Number* Expiration Date* Security Code (3 digits on back of card)* Is the billing address the same as the patient's address above?* Yes No Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Authorization of Fee Payment*In signing this form, I understand and agree to the following regarding billing and payment for charges related to my treatment at Light On Anxiety: 1. There is a 24 hour cancellation policy. When I schedule an appointment and cannot attend a session, I must provide at least 24 hours notice. If I do not provide at least 24 hours notice, I will be charged a $40 cancellation fee. I understand that this cancellation fee will not be covered by insurance. 2. Payment of services (copays and deductibles) is expected at the time of service. If in-network health insurance is used for my sessions, Light On Anxiety will seek reimbursement from the health insurance company. Any unpaid amounts, copayments and deductibles are my responsibility to pay. 3. I authorize recurring charges for fees, copayments and deductibles to be charged to the credit card provided on this form. I authorize the payment of fees to Light On Anxiety for services rendered. I authorize that my card may be used to resolve any and all balances in full for session charges, consultative charges and cancellation fees. I agree to provide payment at the time services are rendered. I agree to maintaining up to date credit card information on file to resolve all balances for services provided, unless otherwise agreed in writing with Light On Anxiety. I understand and acknowledge that late payments may be subject to an additional late payment fee and that ongoing noncompliance with payment terms may incur collection charges if the outstanding balance is not resolved in a timely manner. I agree to the authorization of fee payment as described above.Print Name of Signee (Individual Responsible for Payment)* Signature - Authorization of Fee Payment*Date of Signing* MM slash DD slash YYYY Informed ConsentWhat can I expect from initial visit? The first 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. When will treatment be completed? Light On Anxiety strives to make treatment as effective and efficient as possible. Therefore, progress towards your defined therapeutic goals will be measured frequently. As you move past the challenges that led you to initiate therapy, your therapist will discuss with you the process of terminating treatment as you become your own anxiety coach. What if I need to take a break from therapy? Clients can miss up to two consecutive sessions and still have their weekly spot held. If a client needs to miss three or more consecutive sessions, clients will be connected with our scheduling department in order to review therapist options upon return from break. What if I am experiencng 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 Centers only contracts as an in network provider with Blue Cross Blue Shield of Illinois (BCBSIL) Preferred Provider Organization (PPO), Blue Choice PPO and Aetna. 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 your insurance company. 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 you are a 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 Centers are 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: 25 minute session: $90 40 minute session: $135 55 minute session: $180 Intake sessions (first 2 appointments): $180 each ($360 total) Ph.D Level Clinician: 25 minute session: $130 40 minute session: $195 55 minute session: $260 Intake sessions (first 2 appointments): $260 each ($520 total) 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. In addition, Light On Anxiety staff are 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. Light On Anxiety In Person Treatment Policy Completion of this health consent form is required prior to initiating in person treatment at LOA or entering a LOA office space, in order to maximize health and safety for all. In order for LOA to provide you with in-person services, the following protocols must be followed by clients and providers: (1) All clients ages 5 and older must be fully vaccinated against COVID-19. (2) Hand sanitizer will be provided at the office entrance and must be used upon entering the office. (3) Social distancing requirements must be met. (4) Clients and providers will be required to wear face coverings or masks while in the office as long as encouraged by the CDC. Note: If you do not have a face covering, one will be provided to you. If at any point during your treatment with Light On Anxiety you become ill, your sessions will be moved to our Web-Based Platform until you have been symptom free for 14 days or can provide a negative test result. We remain committed to following state and federal guidelines and to adhering to prevailing professional healthcare standards to limit the transmission of COVID-19 in our offices. Despite our careful attention to sanitization, social distancing, and other protocols, there is still a chance that you will be exposed to COVID-19 in our office. If, at any point, you prefer to stop in-person services or to consider transitioning to remote services, please let us know. By consenting to in-person treatment you acknowledge that there is still a potential risk of exposure and that you agree to follow the safety protocols outlined above in order to engage in in-person services. In addition, you agree that if your health status changes, you will delay entering an LOA office space/receiving in person treatment until you are no longer experiencing COVID-19 (or any other infectious disease) symptoms and have been symptom free for the appropriate time frame, per CDC guidelines. Light On Anxiety Telehealth Treatment Policy Benefits and Risks of Telehealth Telehealth refers to providing services remotely using telecommunications technologies such as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person therapy and telehealth, as well as some risks. For example: Risks to Confidentiality Because telehealth sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. We will take reasonable steps to ensure your privacy, but it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. Data Protection The nature of electronic communications technologies is such that we cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. We will make every attempt to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth). Technology Issues There are many ways that technology issues might impact telepsychology. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies. Appropriateness of Telehealth Usually, we will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work. From time to time, we may schedule in-person sessions to "check-in" with one another. We will let you know if we decide that telehealth is no longer the most appropriate form of treatment for you. We will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services. Emergencies and Technology Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than in traditional in-person therapy. To address some of these difficulties, we will create an emergency plan before engaging in telehealth services. We will ask you to identify an emergency contact person who is near your location and who we will contact in the event of a crisis or emergency to assist in addressing the situation. We will ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency. If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call us back. Instead, call 911, or go to your nearest emergency room. Call us back after you have called or obtained emergency services. If the session is interrupted and you are not having an emergency, disconnect from the session and we will wait two (2) minutes and then re-contact you via the telehealth platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, call us on the phone number provided to you. If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. Fees The same fee rates will apply for telehealth as apply for in-person therapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance provider does not cover electronic telehealth sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to engaging in telehealth sessions in order to determine whether these sessions will be covered. Records We will maintain a record of our session in the same way we maintain records of in-person sessions in accordance with our policies. Consent to Treatment* I consent to treatment. I acknowledge receipt and understanding of Light On Anxiety's informed consent, and agree to all its terms and conditions.Date* MM slash DD slash YYYY Print Name of Signee* Signature - Consent to Treatment* Clinical InformationFrom 0-10 (0 being the least), please indicate your level of emotional distress in the past week.* HiddenFrom 0-10 (0 being the least), please indicate your level of emotional distress in the past month.Please enter a number from 0 to 10.HiddenWhat are your treatment goals at Light on Anxiety?If we had a magic wand and could grant you a wish, what is the first wish that comes to mind? (Don't think too long on this one, just write your first thought.)*What are the top three mental health problems you are experiencing?*On a scale of 0-10, how much distress do these problems cause for you?*Challenge 1Challenge 2Challenge 3 On a scale of 0-10, how motivated are you to move past each of these problems?*Challenge 1Challenge 2Challenge 3 Describe a recent moment where you experienced your top problem. How much distress were you experiencing in that moment (0-10)?Please describe the history of your present problem.*What previously interfered with you moving past these challenges?*How have you been coping with this problem until now?*What would life look like if you made progress in therapy?*Pre-Treatment GAD 7Over the past 2 weeks, how often have you been bothered by the following problems: 1. Feeling nervous, anxious or on edge* Not at all Several days More than half Nearly every day 2. Not being able to stop or control worrying* Not at all Several days More than half Nearly every day 3. Worrying too much about different things* Not at all Several days More than half Nearly every day 4. Trouble relaxing* Not at all Several days More than half Nearly every day 5. Being so restless you can't sit still* Not at all Several days More than half Nearly every day 6. Becoming easily annoyed or irritable* Not at all Several days More than half Nearly every day 7. Feeling afraid as if something awful might happen* Not at all Several days More than half Nearly every day Scoring - Not at all = 0 - Several days = 1 - More than half = 2 - Nearly every day = 3 GAD-7 Score5-9: Mild anxiety 10-14: Moderate anxiety >15: Severe anxiety Clinical HistoryHave you ever had a neuropsychological evaluation?* Yes No When was your most recent neuropsychological evaluation?* Please upload report(s) here: Drop files here or Select files Max. file size: 64 MB. If the report is password protected, please provide the password. Have you ever had outpatient therapy before? If yes, when and what for? What did you find helpful and what did you find unhelpful?*Have you ever received Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), residential or inpatient mental health services before? If so, when and where?*HiddenHave you ever received Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), residential or inpatient mental health services before? If so, when and where? Have you ever experienced a traumatic event? If so, briefly describe experience.* Medical HistoryAre you currently taking any psychotropic medication?* Yes No Current Psychotropic Medication and Dosage* When did you begin taking current medication?* Over the last 7 days, how many did you take your medication exactly as prescribed?*Please enter a number from 0 to 7.Have you taken any psychotropic medication(s) in the past?* Yes No Past Psychotropic Medication(s) and Dosage(s)* Please indicate the date(s) during which you took past psychotropic medication(s).* Describe your current physical health:* Good Fair Poor When was your last annual check-up / physical?* Briefly describe any past or present health concerns.*Please describe your sleep quality.*Do you exercise? If so, what kind of activity, how frequently and how long?*Do you have any difficulties with substance abuse? If yes, please describe such difficulties.* Required Collaborative Care With Psychotropic Medication PrescriberLight On Anxiety values collaborative care with other providers as it helps to create the most integrated and appropriate treatment plan. Please note: If you are using your insurance benefits for Light On Anxiety services, we will attempt to obtain reimbursement for this collaborative care service from your insurance company. If insurance does not reimburse, you will be charged at a prorated private pay rate. We attempt to keep all collaborative care exchanges as quick and effective as possible, typically about 20 minutes. Please inform your therapist if you do not want them to collaborate care with your other providers.If you are taking psychotropic medication, it is required that you provide Light On Anxiety with the contact information and a release of information for the medication prescriber. If at any point during the course of treatment at Light On Anxiety you change medication prescribers, you will be required to complete a release of information for the new provider.As the individual receiving Cognitive Behavioral Therapy (CBT) at Light On Anxiety or Parent or Guardian of Recipient or other person entitled to inspect and copy Recipient’s records pursuant to 740 ILCS 110/4 or, as applicable 42 CFR 2.31 and/or 20 ILCS 301/1-1), I hereby authorize Light On Anxiety to disclose and/or obtain information from my mental health records to the following party (please provide name and contact information for party):Psychiatrist / Psychotropic Medication Prescriber to Exchange Information With* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Email Address Phone Number*Fax Number*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code The purpose of this disclosure is for the following:*Coordinate care and share relevant clinical information on treatment plan, treatment goals and progress to dateThe specific nature of the information to be disclosed is as follows:* Diagnosis and Treatment Plan Entire Record to Date Advanced Consent to Release Information* I hereby acknowledge and agree to Advanced Consent of the release of information detailed in the prior question.Acknowledgement of right to inspect all information disclosed:* I understand and acknowledge that I have the right to inspect and copy any and all information such being disclosed pursuant to this Consent.Acknowledgement of potential consequences of a refusal to consent to release of records:* I understand and acknowledge potential consequences of a refusal to consent to release of records, for example, Light On Anxiety no longer providing therapy or if a third party (not an insurance company) requires these records to pay for therapy, a consequence may be that the therapy will not be paid for.Acknowledgement of Right to Revoke Consent* I understand and acknowledge that I have the right to revoke this Consent at any time. I further understand that any Revocation of this Consent shall be in writing, signed by me or the person who gave the Consent and the signature on the Revocation of the Consent shall be witnessed by a person who can attest to my identity or the identity of the person who signed this Consent and is entitled to sign the Revocation of this Consent. I further understand that no Revocation of this Consent is effective to prevent disclosures of records and communications until it is received by Light On Anxiety. The Revocation of this Consent shall have no effect on disclosures made prior to receipt by Light On Anxiety of the Revocation of Consent.Re-disclosure of Information* I have been made aware that no information disclosed by Light On Anxiety may be redisclosed without my specific consent to redisclose.Copy of Consent Will Be Stored in Patient Record* I understand and acknowledge that a copy of this Consent and a notation as to any action taken thereon shall be entered in my record.This Advanced Consent will expire on the date below:*Note: It is recommended to select a date one year from today. MM slash DD slash YYYY Name of Signee (Recipient of Services at Light On Anxiety or Parent or Guardian of Recipient of Services at Light On Anxiety)* Signature of Recipient or Parent or Guardian of Recipient or other person entitled to inspect and copy Recipient’s records pursuant to 740 ILCS 110/4 (and/or 42 C.F.R. 2.31).*Date Consent Signed On:* MM slash DD slash YYYY Witness attestation to signing of this consent:* I hereby attest to the identity and that I witnessed the individual receiving Cognitive Behavioral Therapy (CBT) at Light On Anxiety or Parent or Guardian of Recipient or other person entitled to inspect and copy Recipient’s records sign this Consent for the Disclosure of Mental Health Records and Communications.Name of Witness to Signing of This Consent* Signature of Witness to Signing of this Consent*Date Consent Signed On* MM slash DD slash YYYY HiddenRelease of Information for Psychotropic Medication Provider I certify that I have a completed a release of information for my/the client's psychotropic medication provider or that I will submit a Release of Information for Psychotropic Medication Provider prior to 2nd session at Light on Anxiety.. Recommended Collaborative Care With All Healthcare ProvidersIt is recommended that you provide Light On Anxiety with the contact information for all health care providers you are currently seeing or have seen in the last 6 months in order to incorporate all relevant health information into our treatment plan for you. Primary Care Physician Name First Last PhoneEmail Other Provider First Last PhoneEmail Additional Releases of InformationIf you would like Light On Anxiety to coordinate care with any other individuals or providers on your behalf, please complete an additional release of information. Note: To ensure progress on intake form is not lost, right click on the link to open the release of information in a new tab/window. Family HistoryPlease describe any family history of significant psychiatric problems.*Has anyone in your immediate family died by suicide?* Yes No Please describe your childhood family experience:* Outstanding home environment Normal home environment Chaotic home environment Witnessed physical/verbal/sexual abuse toward others Experienced physical/verbal/sexual abuse from others Other If other, please indicate. Give a description of parent/guardian 1's personality and parenting style.* Give a description of parent/guardian 2's personality and parenting style. Give a description of sibling relationships. Relationship HistoryPlease select:* Single Married Divorced Separated Widowed Committed relationship Partnered Engaged Remarried Other If client is parent, please indicate ages of children. How satisfied are your with current family life?* Have you ever been in an emotionally, physically, or sexually abusive relationship?* Do you often feel like you have to please other people in order to maintain a friendship or relationship?* How satisfied are you with current friendships?* Developmental HistoryCheck any of the following that applied during childhood:* Delays in developmental milestones Received speech therapy Received occupational therapy Difficulty separating from caregiver when transitioning to school setting Nail biting, skin picking or hair pulling Medical problems Social challenges History of bullying History of abuse/neglect Child of alcoholic/addict School problems Alcohol/drug use Oppositional behaviors Other None of the above If other, please indicate: Feel free to elaborate on any of the above responses.Educational HistoryHighest Level of Academic Pursuit* High School Vocational Training College Graduate School Average Grades:* Disciplinary problems?* Aspects of school that excel/excelled in:* Aspects of school that struggle/struggled in:* Has there ever been a period of excessive absences during the school year? If so, please explain.* History or suspected history of learning or attentional concerns:* History or bullying or teasing at school?* Overall feelings and attitude towards school:* Employment HistoryAre you currently employed? If so, what is your profession?* Do you enjoy your current line of work?* Have you ever been fired from a job? If so, please explain:* Have you ever been arrested? If so, please explain.*
