Client Information

Name

First NameLast Name

Gender

MaleFemaleTransgenderNon-binary

Parent/Legal Guardian name (if under 18)

First NameLast Name

Birthdate

Date

Marital status

SingleMarriedDivorcedWidowed

Employment status

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number-cell

Please enter a valid phone number.

Phone Number-home

Please enter a valid phone number.

Email address

example@example.com

Do you consent to correspondence regarding appointments via email?

YesNo

Do you consent to correspondence regarding appointments via text?

YesNo

If you are using health insurance is your policy held by:

YourselfSpouseParent/GuardianOther

Policy holder birthdate

Date

Copy of Health Insurance (front and back)

Photo Identification

Emergency contact

First NameLast Name

Emergency contact phone

Please enter a valid phone number.

Emergency contact relationship

I hereby authorize Anne G. Walker LCSW to furnish information to insurance carriers concerning concerning my care. I hereby authorize benefits to be paid directly to her for mental health treatment services rendered to me or my dependents. I understand that I am responsible for any amount not covered by health insurance. I am aware that unpaid balances beyond 90 days will be considered past due and can be forwarded to a collection agency.

I agree to not use any recording devices during a session without specific prior consent between myself and Ms. Walker. This is to ensure a safe and therapeutic environment for all clients. Unauthorized recording is in violation of Illinois law and will be reported to the authorities.

Unless canceled 24 hours in advance I understand the policy to is be charged for a missed session at a fee of $125. I will be directly billed for this fee as unattended sessions cannot be billed to an insurance carrier.

I have received a copy of Ms. Walker's office policies that further detail communication, rates for services, and office health and safety standards as well as Notice of Privacy Practices and agree to proceed with care.

Signature

Clear

Date