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)
Best phone number to reach client (or parent/guardian)
Client's Date of Birth
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.
Insurance Policy Holder's Name
Member ID #
Customer Service Phone Number
(BCBS/IL - 800-972-8088)
on insurance card
Susan Anewalt (Sliding Scale Availabile)
Giuseppina Impellizzeri (Art Therapy)
I'm not sure. Please help me choose a therapist that is right for me
Brian Kelley (Not Accepting New Clients)
Irina Sheppard (Sliding Scale Available)
Lauren Breit (Not Accepting New Clients)
Christine Nicklos (Art Therapy)
What would you like to address in therapy?
A sentence or two will do. (e.g., depression, anxiety, marriage problems. . . )
How did you hear about The Center for Self-Actualization?
In just a few words
When are you available for therapy?
Please check all that apply.
Mon -Fri Mornings (8am-noon)
Mon -Fri Afternoons (noon-5pm)
Mon -Fri Evenings (5-10pm)
Saturday Mornings (8am - noon)
Saturday Afternoons (noon-5pm)
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