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Grace Integrated Lombard, Westmont, Oak Brook, Riverside & Chicago Intake Form
Welcome! Thank you for taking the time to complete this form thoroughly, including insurance information, as that will reduce your wait time to be paired with the right clinician. We value your privacy and the only individuals who have access to this form are those who will be helping you get started on your therapeutic journey. Once you have completed the form a scheduling coordinator will be in contact within 7 business days. You can also follow up via email at
scheduling@graceintegrated.com
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Email
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Your email
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MM
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DD
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Name of Person Completing this Form:
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Your answer
What type of therapy are you seeking?
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Individual
Couples
Family
Name of Client (if different from above) or NA:
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Your answer
Client date of birth:
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Your answer
Phone:
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Your answer
Can a Voicemail be left on the phone number provided:
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Yes
No
Required
Private Email Address that can be used for Follow Up:
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Your answer
Preferred method of communication:
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Phone
Email
Primary Insurance Carrier Name - (For HMO plans, include the site affiliation (AMITA, Duly, Edwards/Elmhurst, Loyola, RUSH, etc.)) Or Identify as Self-Pay.
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Your answer
Insurance/s Member ID number with 3 Alpha Prefix (of client):
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Your answer
Insurance Group number (of client):
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Your answer
Is this an HMO or PPO policy
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HMO
PPO
Do you have a secondary insurance policy?
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Yes
No
Address on file with insurance (for insurance verification)
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Your answer
Any current family member attending services at Grace who share the same insurance and method of payment so accounts can be linked. If yes, enter client Name. If No, enter: None.
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Your answer
Identify your top 3 choices in order of preference:
First Choice
Second Choice
Third Choice
Riverside In-Person limited availability
Oak Brook In-Person
Westmont In-Person
Lombard In-Person
Chicago In-Person
Telehealth
First Choice
Second Choice
Third Choice
Riverside In-Person limited availability
Oak Brook In-Person
Westmont In-Person
Lombard In-Person
Chicago In-Person
Telehealth
Clear selection
Availability for ongoing therapy appointments (select all that apply):
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Morning (9a - 11a)
Early afternoon (11a - 3p)
Late afternoon (3p - 4p)
Evening (4p - 6p) there is limited availability
Required
Preferred Identification of Clinician:
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Male
Female
Nonbinary
First Available
Clinician Specialty (examples such as couples, individual, christianing, parenting, Spanish speaking, anxiety, depression, etc.):
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Your answer
How did you find us?
Social Media
Referred by Doctor
Referred by a Friend
Referred by a Current Client
Referred by your Insurance
Drove by one of our Sites
Church Bulletin
Other:
Who Referred You? (If a MD, include Dr. Name and yes/no if you have a referral. Otherwise, include name of referring person/organization):
Your answer
Reason for requested counseling at this time, please be as detailed as you can:
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Your answer
Are you currently living in Illinois? Please note we are only licensed in Illinois. Anyone residing outside IL can only be seen six times by our clinical team.
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No
Yes
Gender listed on Insurance
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Male
Female
Are you seeking counseling services under any of the following:
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EAP Services
Workman's Comp
Pending or Ongoing Court Case
Hormone Replacement Therapy Requirement/or Gender Affirming Letter
Seeking Animal Assisted Letter
FMLA
None of the Above
Required
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