KC Counseling Insurance Intake Form 
If you’d prefer to email, text, or call us directly, our
contact is:

kccounselingllc.2019@gmail.com

217-377-0299

*If one of the following does not apply, please write "NA" and move on to the next question*

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Client First Name: Person seeking services  *
Client Preferred Name: Person seeking services *
Client Last Name: Person seeking services  *
Client Preferred Pronouns: Person seeking services *
Client Legal Sex: Used for billing insurance claims. Has to match what insurance has on file.  *
Client Date of Birth: Person Seeking Services *
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Client Phone Number: If a minor, please list the phone number of the primary guardian/contact person. *
Email Address: If a minor, please list the email address of the primary guardian/contact person. This is the email address we will send all invoices, appointment reminders, and client portal links.  *
If Minor: Contact First Name  *
If Minor: Contact Last Name 
 *
Mailing Address: House Number and Street Name  *
Mailing Address: City  *
Mailing Address: State *
Mailing Address: Zip Code *
Insurance Company Name (If no insurance, please write NA, and we will reach out to discuss self-pay options) *
Insurance Company Phone Number: Located on the back of the insurance card: (if no insurance, write "NA")  *
Insurance Member ID Number (if no insurance write "NA) *
Insurance Group Number (If no insurance, write "NA") *
Primary Subscriber of the Insurance Policy: Client's Relationship to Primary Subscriber (read as: The Primary Subscriber is the Client's [enter answer choice here]) *
Primary Subscriber of the Insurance Policy: First Name (If client is the primary subscriber write "self") *
Primary Subscriber of the Insurance Policy: Last Name
 *
Primary Subscriber of the Insurance Policy: Legal Sex (Used for billing insurance claims. Has to match what insurance has on file) *
Primary Subscriber of the Insurance Policy: Date of Birth
 *
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Primary Subscriber of the Insurance Policy: Phone Number
 *
Primary Subscriber of the Insurance Policy: Address, include the following: House number, street name, city, state, and zip code
 *
Do you have Secondary Insurance? *
Secondary Insurance Company Name (If no insurance, please write NA, and we will reach out to discuss self-pay options) *
Secondary Insurance Company Phone Number: Located on the back of the insurance card: (if no insurance, write "NA")  *
Secondary Insurance Member ID Number (if no insurance write "NA) *
Secondary Insurance Group Number (If no insurance, write "NA")
 *
Primary Subscriber of the Secondary Insurance Policy: Client's Relationship to Primary Subscriber (read as: The Primary Subscriber is the [enter answer choice here])
 *
Primary Subscriber of the Secondary Insurance Policy: First Name (If client is the primary subscriber write "self")
 *
Primary Subscriber of the Secondary Insurance Policy: Last Name
 *
Primary Subscriber of the Secondary Insurance Policy: Legal Sex (Used for billing insurance claims. Has to match what insurance has on file) *
Primary Subscriber of the Secondary Insurance Policy: Date of Birth
 *
MM
/
DD
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YYYY
Primary Subscriber of the Secondary Insurance Policy: Phone Number
 *
Primary Subscriber of the Secondary Insurance Policy: Address, include the following: House number, street name, city, state, and zip code
 *
How would you prefer to have sessions? Please select one of the following options.
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Do you have any accessibility needs (e.g., wheelchair access, difficulty with stairs) that we should consider when scheduling your appointments?
 *
Please list 3 preferred days and times for your first appointment (scheduled between 10 AM–5 PM and lasting 1 hour). After this initial session, we’ll match you with a clinician based on both your needs and the clinician's expertise, as well as mutual availability for future sessions.
What services are you seeking? Please check ALL the services you are interested in *
Required
Message: Please provide a brief message below noting what brings you to therapy and any additional details *
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