Section 1 of 9
Walk With Me Counseling Intake Form
Welcome, and thank you for reaching out. We're honored that you're considering therapy with us!
Before we move forward, please complete this short form. It helps us confirm that we're a good fit and match you with the right therapist for your free 15-minute consultation.
This form takes about 5–7 minutes to complete.
Your privacy is important to us. All personal information provided will be kept confidential, used only for the purposes you consent to, and protected through our HIPAA-compliant intake form
Before filling out this form, please confirm the following:
✔ I have Blue Cross Blue Shield PPO, Aetna PPO, or I will pay out of pocket at $155 per session
✔ Walk With Me Counseling Center does not accept Medicaid, Medicare, HMO plans, United Healthcare, Cigna, or sliding scale options
✔ All therapy sessions are held virtually through our HIPAA-compliant EHR SimplePractice (similar to Zoom)
If you do not reside in Illinois (including telehealth) we will not be able to service you due to laws regarding licensure across state lines
Your privacy is important to us. All personal information provided will be kept confidential, used only for the purposes you consent to, and protected through our HIPAA-compliant intake form.
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Section 2 of 9
If you're in immediate danger or need urgent support, please call 911 or the Suicide & Crisis Lifeline at 988.
Section 3 of 9
First Name
First Name
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Last Name
Last Name
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Date of Birth
Date of Birth
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Email Address
Email Address
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Phone Number
Phone Number
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Is it okay to text you with updates about your out of pocket cost?
Is it okay to text you with updates about your out of pocket cost?
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No, I prefer email
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Section 4 of 9
Times Available for Weekly Therapy
We meet with clients weekly because therapy is most effective when it’s consistent. Weekly sessions help you stay supported, process what comes up in real time, and build real progress instead of starting over each time.
Which days/times are you generally available for weekly therapy? Check all that apply.
Walk With Me Counseling Center is Closed on Saturday and Sunday.
Which days/times are you generally available for weekly therapy? Check all that apply.
Walk With Me Counseling Center is Closed on Saturday and Sunday.
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Monday (morning)
Monday (afternoon)
Monday (evening)
Tuesday (morning)
Tuesday (afternoon)
Tuesday (evening)
Wednesday (morning)
Wednesday (afternoon)
Wednesday (evening)
Thursday (morning)
Thursday (afternoon)
Thursday (evening)
Friday (morning)
Friday (afternoon)
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Do you have a preferred therapist?
Do you have a preferred therapist?
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No preference/first available therapist
Deja Phillips
Veleka Avant
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Section 5 of 9
How Did You Find Us?
How did you find us?
How did you find us?
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Google
Psychology Today
Friend or family member
Monarch
Istagram
Facebook
Another therapist
Other
Other:
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Are you filling this out on behalf of someone else ?
Are you filling this out on behalf of someone else ?
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Are you insured?
Are you insured?
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Section 6 of 9
Insurance
We are currently only in network with Aetna PPO BCBSIL PPO plans. If you would like to still receive services, we can provide you with a superbill for possible reimbursement with your insurance carrier.
Primary Insurance Carrier (i.e. BCBS, Aetna, etc.)
Primary Insurance Carrier (i.e. BCBS, Aetna, etc.)
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Member ID# (Please Double Check)
Member ID# (Please Double Check)
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Group Policy #
Group Policy #
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Policy Holder First Name
Policy Holder First Name
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Policy Holder Last Name
Policy Holder Last Name
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Please Upload the FRONT of your insurance card
Please Upload the FRONT of your insurance card
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Add file
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Please Upload the BACK of your insurance card
Please Upload the BACK of your insurance card
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Are you covered under more than one policy ?
Are you covered under more than one policy ?
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Yes
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No
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Section 7 of 9
Secondary Insurance
We are currently only in network with Aetna PPO BCBSIL PPO plans. If you would like to still receive services, we can provide you with a superbill for possible reimbursement with your insurance carrier.
Secondary Insurance Carrier
Secondary Insurance Carrier
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Secondary Insurance Policy Holder First Name
Secondary Insurance Policy Holder First Name
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Secondary Insurance Policy Holder Last Name
Secondary Insurance Policy Holder Last Name
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Secondary Insurance Policy Member ID#
Secondary Insurance Policy Member ID#
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Secondary Insurance Group #
Secondary Insurance Group #
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Please Upload the FRONT of your insurance card
Please Upload the FRONT of your insurance card
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Add file
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1
5
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1 MB
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Please Upload the BACK of your insurance card
Please Upload the BACK of your insurance card
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Add file
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1
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10
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1 MB
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Section 8 of 9
Acknowledgment of Agreement
I understand that Walk With Me Counseling Center will provide an estimate of my insurance coverage (if insured), but it is ultimately my responsibility to fully understand the details of my insurance coverage.
I acknowledge that I am responsible for paying my balance at each session, which includes any copays, co-insurance, and/or deductible amounts. The card I have on file will be charged for the full balance owed for each session.
I agree to receive email and/or text communications from Walk With Me Counseling Center and understand that I can opt out at any time.
I understand that completing this form does not guarantee an appointment. My appointment will only be confirmed once all intake documents have been completed in the client portal.
By typing my full name below, I acknowledge that I have read and agree to the terms outlined in this form
By typing my full name below, I acknowledge that I have read and agree to the terms outlined in this form
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Section 9 of 9
What happens next?
Once you complete this form, we’ll verify your insurance benefits (if applicable) and email you with your exact out-of-pocket cost within 24–48 hours. If you're comfortable with the cost, we’ll send your intake documents and a link to schedule your session.
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