Request for Counseling Services*

Psychological Services of Central Illinois, P.C.

*This form may only be used to request counseling services. Requests for neuropsychological evaluations require a formal physician's referral to be faxed to our office by your physician. Requests for evaluations sent via this form will not be processed.

Patient Details

First Name

Middle Name

Last Name

Date of Birth

INVALID DATE OF BIRTH - PLEASE CORRECT TO PROCEED

Please Note: We are not able to see patients for counseling who are under the age of 17

Guardianship Information

Please select the statement that correctly reflects the patient's guardianship status

The patient is their own legal guardian The patient's legal guardian is the following individual:

First Name

Last Name

Relationship to Patient

Phone Number

Address

Contact Information

Email Address

Street Address

Apt./Suite #

City

State

Zip Code

Primary Phone Number

Add Additional Phone Number(s)

Emergency Contact (please list at least one person who we can contact in case of an emergency)

Add Emergency Contact

Financial/Insurance Information

ResponsibleParty Who is responsible for any patient amounts due?

The Patient Someone Else

First Name

Last Name

Address

Phone Number

Billing Option

Yes, please bill my insurance (info listed below) No, I do not have insurance, or I do not wish to use my insurance.

Add Insurance Plan

Upload Copy(ies) of your insurance card(s) (Optional)

Add file

Please upload a file

Personal Information (Optional - please feel free to skip this section if you don't feel comfortable answering these questions)

Gender Identity (if different than legal gender)

Identified Pronouns

Sexual Orientation

Race/Ethnic Identity

Religion (if applicable)

Family Information (please list other members of your household who are living with you)

Add Household Member

Providers (please list your physician and/or any other medical or behavioral health providers you see)

Add Provider

Previous Services

Were you referred to our practice?

Yes No

Who referred you?

Have you sought counseling in the past?

Yes No

When and where?

Medications

Please select one of the following options:

I will type in the medication information I will upload a medication list The patient does not take any medications at this time

Add Medication List Please click here to upload a copy of the patient's medication list

Add file

Please upload a file

Add Medication

Medical History

Medical History Selection

The patient has no known medical conditions The patient has the following medical conditions (please list):

Please list any medical conditions you have

Other Information

What is your present occupation?

What is the highest level of education you have acheived?

Please list any legal issues

What do you consider to be a personal strength?

What do you consider to be a personal weakness?

What do you like to do to relax?

Reason for Consultation

Please describe the problem(s)/concern(s) that brought you here:

What do you hope to achieve in therapy?

Is there any other information you would like us to have that isn't listed anywhere else?

Thank you for taking the time to provide us with this information. These details assist us helping to match you up with the therapist who has the most experience working with the challenges that you are facing. Once we process this information, a staff member will reach out to you to set up an appointment with your assigned therapist.

This form is incomplete, and this request will NOT be processed

Please correct the patient's DOB to see and complete the remaining information. Thanks!

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