Personal Information

Full Name (First, Middle, Last Name)

Preferred name

Pronouns

Date of birth

Address

Address Line 1

City

State

Zip Code

Phone

Email

How did you find us?

Goals and Preferences

Preferred therapist(s)

What goals do you hope to achieve?

What are your scheduling preferences for weekly sessions?

Place of sessions

Virtual Office via Telehealth
In-Person

Modality

Individual psychotherapy
Couples Counseling

Your Partner's information

Partner Full Name

Partner Preferred name

Partner Date of birth

Partner Phone

Partner Email

Does your partner live at the same address?

Yes
No

Partner Address

Address Line 1

City

State

Zip Code

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.

Yes
No

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
No

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 ID (front and back)

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

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

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.

Is a resident

I am currently an Illinois or District of Columbia resident.

Is an adult

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