Section 1 of 7
Walk With Me Counseling Intake Form
Welcome—we’re so glad you’re here!
This form helps us collect what we need to verify your insurance and confirm your cost before scheduling your first session.
It only takes a few minutes. If you have any questions, we’re here to walk with you every step of the way.
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 7
If you're in immediate danger or need urgent support, please call 911 or the Suicide & Crisis Lifeline at 988.
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 3 of 7
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
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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 4 of 7
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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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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Section 5 of 7
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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Date
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Add file
View folder
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1
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10
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1 MB
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Section 6 of 7
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 7 of 7
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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