Self-Pay / Out-of-network Inquiry Form

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. If you are going to apply for out-of-network reimbursements from your insurance provider, we are not able to submit out-of-network claims on your behalf but we can provide you monthly superbills for you to submit to your insurance company and we recommend you to use services such as Reimbursify.com.

If you prefer using your in-network insurance benefits, please submit our Insurance Verification Form instead.

If you would like to learn more about our practice’s policies, please visit our Frequently Asked Questions (FAQ) page.

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Personal Information

Full Name (First, Middle, Last Name) *

Preferred name

Pronouns

Date of birth *

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Address *

Address Line 1

City

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

Zip Code

Phone *

Email *

How did you find us? *

Goals and Preferences

Preferred therapist(s) *

• Any
• Kathleen Truby
• Drae Laws
• Erica Cole
• Gwendolyn Hickey
• Raechel Pierce
• Raquel Hennessey
• Sarena Korni
• Izzy Jimenez
• Rebecca Corpuz Swanney
• Izabella Bebenek
• Teri Zeinz
• Yingning Wang
• Elisa Diaz
• Aleksandar Kajmakoski

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 *

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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

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).

Submit