New Client Paperwork
Prior to arriving at your first appointment, please fill out the following and click "submit". If you plan to use insurance to pay for your services, The Center for Self-Actualization will verify your benefits before your first session.
Client's Name (Last, First) *
Your answer
Best phone number to reach client (or parent/guardian) *
Your answer
Client Email *
Your answer
Client's Date of Birth
MM
/
DD
/
YYYY
What is your preferred method of contact? (By checking one of the following you are consenting to being contacted in that way.) *
Will you be using insurance to pay for services? *
If no, please skip the remainder of the questions below.
Insurance company name:We are in-network with BCBS PPO, Blue Choice PPO, TraditionalBlue, or BasicBlue.
If we are not in-network with your insurance provider, we will verify your out-of-network benefits and/or work with you on a sliding scale if needed.
Your answer
Insurance Policy Holder's Name
Your answer
Member ID #
Your answer
Group #
Your answer
Customer Service Phone Number

(BCBS/IL -  800-972-8088)

on insurance card
Your answer
Requested therapist *
What would you like to address in therapy? *
A sentence or two will do. (e.g., depression, anxiety, marriage problems. . . )
Your answer
How did you hear about The Center for Self-Actualization?
In just a few words
Your answer
When are you available for therapy? *
Please check all that apply.
Required
Submit
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