Child & Adolescent Therapy

Sometimes, kids and teens need extra support to navigate life’s challenges. At Roamers Therapy, we offer therapy for children and adolescents in a way that feels natural, supportive, and affirming. Whether they’re dealing with anxiety, school stress, friendships, self-esteem, or big life changes, we create a safe space for them to express themselves and build confidence.

Our therapists use evidence-based approaches like Cognitive Behavioral Therapy (CBT) and Play Therapy to help kids and teens develop healthy coping skills. We also work closely with parents to ensure the support continues beyond the therapy room. No one should have to figure it all out alone.

Initial Inquiry Form For Child And Adolescent Therapy

Click here to access our FAQ (Frequently Asked Questions) Page

Please fill out the form below to inquire about availability and your costs.

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Choose One *

• Both parents/legal guardians are living, have legal custody of the minor child, consent to treatment
• One parent/legal guardian has legal custody of the minor child and both parents consent to treatment
• One parent/legal guardian is absent, missing, or deceased and only one parent has consent to treatment

Parent/Legal Guardian I's Information

Parent/ Legal Guardian I's Full Name *

Date of Birth *

Email *

Phone *

Address *

Address Line 1

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Parent/Legal Guardian II Information

Parent/Legal Guardian II's Full Name *

Date of Birth *

Email *

Phone *

Address *

Address Line 1

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Minor (Children) Information

Minor's Full Name *

Date of Birth *

Email

Phone

Address *

Address Line 1

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Goals & Preferences

Preferred Therapist *

• Any
• Drae Laws
• Erica Cole
• Raquel Hennessey
• Aleksandar Kajmakoski
• Elisa Diaz
• Sarena Korni
• Yingning Wang
• Rebecca Swanney

What goals do you hope to achieve? *

What are your scheduling preferences for weekly sessions? *

Preferred Location *

• South Loop (47 W Polk St, Chicago, IL 60605)
• Lakeview (1300 W Belmont Ave, Chicago, IL, 60657)
• Virtual via Telehealth

I's out-of-network Full

Insurance Info

• Insurance
• Self-pay

Primary insurance Carrier's name (BCBS PPO/Aetna/Cigna etc.) *

Policy Holder's Name *

Group Number *

Member ID Number *

Miscellaneous

Will you request superbills for out-of-network benefits reimbursement from your insurance company? *

• Yes
• No

*

• I understand that Roamers Therapy practice will not be billing insurance for me and I will only receive a receipt for services.

*

• I understand I would be responsible for submitting claims to my insurance plan if I would like to use my out-of-network benefits and Roamers Therapy will not hold any responsibility in this process.

Will you request us to produce any paperwork? *

• Yes
• No

(e.g., motional support animal letter, FMLA paperwork, short term disability paperwork, court documents)

Please briefly explain the nature of your paperwork request *

Please note that we are not able to accept paperwork requests by new patients. We also have a correspondence policy that requires:
  * Establishing a clinical relationship of 12 weeks or more,
  * If applicable, following up on your therapist’s referrals for higher level of care and psychiatric services,
  * and a correspondence fee of $150.00/hour for producing documents and medical records.
You can read more about our policy in the Frequently Asked Questions page.

Roamers can deny document requests *

• I understand and acknowledge that Roamers Therapy reserves the right to deny a document request if medical necessity is not established.

Identification Documents

Government IDs of parents/legal guardians (front and back) *

Click or drag files to this area to upload. You can upload up to 4 files.

e.g., Driver’s License, State ID card, Passport Card, Passport first page, or similar.

Birth certificate or legal documentation of said guardianship of minor *

Click or drag files to this area to upload. You can upload up to 2 files.

Insurance Card (front and back) *

Click or drag files to this area to upload. You can upload up to 2 files.

Please only upload photos of your insurance card.

Acknowledgements

Agrees with Roamers Policies *

• I agree with Roamers Therapy’s Fee Schedule and Policies.

Click here to read our Fee Schedule and Policies.

Is a resident *

• I am currently an Illinois resident.

Additional documentation *

• In cases where additional documentation is necessary to confirm that the parent/legal guardian holds legal custody of the minor, parent/legal guardian will provide to Roamers Therapy.

Consent forms *

• Legal consent forms will be signed by the parent/legal guardian to authorize the provision of therapeutic services.

14-18 *

• In accordance with legal and ethical guidelines, minors aged 14 and older are required to sign the legal consent form in addition to the consent provided by their parent/legal guardian.

Submit