Starting Services at Roamers Therapy

To start services at Roamers Therapy, please complete the form below and identify whether you would like to use insurance benefits or self-pay for services.

If you plan to use insurance benefits, we will verify your benefits and send you a confirmation e-mail regarding your estimated out-of-pocket expenses and availability for your preferred clinician. This process usually takes 1 to 2 business days. However, we encourage you to also call your insurance company to become familiar with your specific benefits and coverage. Please note that verification of benefits does not guarantee payment from your insurance company and this is only a quote of benefits.

If you plan to self-pay or use out-of-network benefits, we will send you a confirmation e-mail regarding clinician availability and next steps for beginning services. We can also provide monthly superbills for reimbursement purposes for you to submit to your insurance provider. Please note that we are not able to submit out-of-network claims on your behalf. We also recommend you to use services such as Reimbursify.com to help simplify the reimbursement process.

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Personal Information

Full Name (First, Middle, Last Name) *

Preferred name

Pronouns

Date of birth *

Phone *

Email *

How did you find us? *

Which state are you physically located in? *

• Illinois
• Washington, D.C.

Will be in IL at all times? *

• I will be physically located within Illinois (IL) during all of my sessions.

Will be in DC at all times? *

• I will be physically located within Washington, D.C. (DC) during all of my sessions.

Address *

Address Line 1

City

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

Zip Code

Which option best describes how you plan to pay for services? *

• Using insurance benefits
• Self-pay / out-of-network benefits

Goals and Preferences

Preferred therapist(s) *

• Any
• Kathleen Truby
• Erica Cole
• Raquel Hennessey
• Izzy Jimenez
• Rebecca Corpuz Swanney
• Izabella Bebenek
• Yingning Wang
• Aleksandar Kajmakoski
• Vanessa Adan
• Aradhana Walker
• Annie Scoltock
• Morgan Cureton
• Chelsey Daval
• Jessica Sandoval
• Natalie Hogue

Preferred therapist (DC-only) *

• Any

What goals do you hope to achieve?

What are your scheduling preferences for weekly sessions? *

Place of sessions *

• Virtual Office via Telehealth
• In-Person

Preferred location *

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

Modality *

• Individual Psychotherapy
• Couples Counseling
• Child Psychotherapy
• Family Therapy

Parent/Legal Guardian I

Full Name *

Phone *

Email *

Do you live at the same address with the minor? *

• Yes
• No

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

Full Name

Phone

Email

Do you live at the same address with the minor?

• Yes
• No

Address

Address Line 1

City

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

Zip Code

Your Partner's information

Partner Full Name *

Partner Preferred name

Partner Date of birth *

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Partner Phone *

Partner Email *

Does your partner live at the same address? *

• Yes
• No

Partner Address *

Address Line 1

City

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

Zip Code

Family Member's Information

Full Name of Other Family Member

Family Member Preferred Name

Family Member Date of birth *

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Family Member Phone *

Family Member Email *

Does the family member live at the same address? *

• Yes
• No

Family Member Address *

Address Line 1

City

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

Zip Code

Insurance information

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

Policy Holder's Name *

Relationship to Client *

• Self
• Parent
• Significant Other or Spouse

Policy Holder's Date of Birth *

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Policy Holder's Phone Number *

Policy Holder's Address *

Address Line 1

City

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

Zip Code

Group Number *

Member ID Number *

Do you have a secondary insurance plan?

• Yes
• No

Name of Secondary Insurance Carrier *

Will you be utilizing HSA/HRA/FSA or similar plans?

*Please note that we are unable to accept EAP plans or other short-term coverage options.

Self-Pay / Out-of-network

If you prefer paying for your mental health services out-of-pocket, or use your insurance plan’s out-of-network benefits, please submit your inquiry using the form below.

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. *

• Yes

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. *

• Yes

Miscellaneous

Will you request us to produce any paperwork? *

• Yes
• No

(e.g., emotional 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

Insurance Card (front and back) *

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Please only upload photos of your insurance card.

Government ID (front and back) *

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

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

Birth certificate/legal custody document of the minor *

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Acknowledgements

Agrees with Roamers Policies *

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

Click here to read our Fee Schedule and Policies.

Holds Medicare/Medicaid *

• I am not insured through Medicaid or Medicare.

Click here to read our Fee Schedule and Policies.

Is a resident *

• I am currently an Illinois or Washington, D.C. resident.

Is an adult *

• I am an adult (18 years old or older).

Date / Time

Date

Time

Submit

If you are planning to utilize an additional funding option (e.g., HSA, HRA, FSA, EAP, etc), please provide detailed information and consult with your employer to guarantee payment for mental health services.  

Accepted Insurance: Blue Cross Blue Shield PPO, BCBS – Blue Choice PPO, Aetna, and Cigna, Oscar, and United Healthcare.

• Roamers Therapy does not accept any other EAP, HMO, Medicaid, nor Medicare plans. Please contact your customer service line that can be found on your insurance card to locate a provider that does. 

Scheduling Frequency: Roamers Therapy works off a weekly scheduling model and we are not able to accommodate any infrequent scheduling, such as (bi-weekly, monthly, or sporadic). 

1. Research shows that clients who go to psychotherapy on a weekly basis either make significantly more progress or deteriorate much less compared to those who go to psychotherapy on a biweekly/sporadic basis.
2. Our clinicians too, noticed in the past years that their clients did not reach desired psychotherapy goals and experienced adverse effects during bi-weekly scheduling.  
3. Psychotherapy Modalities utilized for individual and couples therapy highly recommend weekly scheduling to see folks meet their goals and improve functioning.

If you have any additional questions, please use our frequently asked questions page:

Click here to access our Frequently Asked Questions (FAQ) page.