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).