New Client Forms

Welcome to my practice! At the present time, I am accepting new clients for adult ADHD assessments only. My goal is to assess you as carefully and thoroughly as possible. Please help me by following these 4 steps. Please allow at least 30 minutes. I will send you a link for a confidential dropbox that you can use to submit your forms before your first appointment. Please note that I need these forms at least 24 hours in advance of your appointment time.

1

Fill out my new client form [PDFWord DocApple Pages]. There is a lot of information about mental health treatment and then some forms to fill out.  Please review this carefully. Please upload the new client form in either Word or pdf format.

2

Fill out the Informed Consent Addendum for Phone or Video Chat Sessions form [PDFWord DocApple Pages]

4

If you have a significant history of depression or anxiety, please fill these out:

5

Fill out the Credit Card Form. You will be given an option to pay by Zelle or Venmo later if you prefer.

6

Upload copies of the front and back your insurance card.  Photos are fine.

7

This step applies to you only if you are paying out of pocket or you are uninsured--not if you have Blue Cross PPO or Medicare.  You have rights under the No Surprises Act--access these rights here to review them.  If you are coming for an assessment of ADHD, here is your Good Faith Estimate for your review.

8

Fill out the Release of Information Form for your psychotherapist and your prescriber (if you have them).  

9

Upload all of the documents into your confidential dropbox.  You should have at least 7 different documents. Word, pdf or photos are ok. Please do not upload documents in pages format. 

 

Contact me

I am not currently accepting new psychotherapy clients at this time; I am only seeing new clients for ADHD assessments. Please note: All meetings are by video.

Lincoln Square
2334 West Lawrence Avenue
Suite 212
Chicago, Illinois 60625

773.859.1822