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

Please enable JavaScript in your browser to complete this form.

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
• Dan Crotty

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 *

MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

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