Family Service: Prevention, Education & Counseling

Intake Forms

Please complete these intake forms prior to your first appointment. Please call our intake line at 847-432-4981 ex. 39,

if you have any questions about the forms or will be unable to complete the forms before your appointment. If you are

unable to complete the forms before your first appointment, then you will need to make arrangements to arrive 30 minutes

prior to your appointment to complete the necessary paperwork.

PAPERWORK MUST BE COMPLETED PRIOR TO YOUR FIRST COUNSELING SESSION.

· Intake cover Page

· Mental Health History

· Informed Consent for Treatment

· Insurance Worksheet

· Insurance Verification (if you are using insurance to pay for your counseling sessions)

· Financial Hardship Application (if you are applying for reduced fee counseling)