SUSAN O’CONNELL, LCPC

Individual, Couple, and Family Counseling

527 Romona Rd
Wilmette, IL 60091
(847) 604-1240

CLIENT APPLICATION FORM                   Date:  _______________________________

Primary Client   Last Name               First                 MI         Birthdate              Male     Female

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Home Address:                                                 City                  State                Zip Code

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Email  Address:
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Home Phone:                                                   Cell Phone                                              Work Phone

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Social Security Number:
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Marital Status (circle one)    Single  Married   Separated   Divorced   Remarried  
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Occupation (If student, school & grade or year)
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Guarantor (if different from Primary Client)

Last Name               First                 MI         Birthdate              Male     Female

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Home Address:                                                 City                  State                Zip Code

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Home Phone:                                                   Cell Phone                                Work Phone

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Social Security Number:
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Marital Status (circle one)    Single  Married   Separated   Divorced   Remarried  
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Occupation (If student, school & grade or year)

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Primary Insurance                            Policy/Group#

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Address                                               City                  State    Phone

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Policy Holder                         Social Security#                      Relationship            

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Address                                               City                  State    Phone

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Employer’s Name:

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Secondary Insurance                     Policy/Group#

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Address                                               City                  State    Phone

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Policy Holder                         Social Security#                      Relationship

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Employer’s Name:

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Emergency Contact Name               Phone                          Relationship to Client

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Family Members and Other Key Persons:

Name                                      Sex   Birthdate  Occupation      Marital    Relationship to

                                                                          Or School Yr.  Status            Client
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Referral Source:       Name                          Daytime Phone           Evening Phone

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Address                                               City                  State                Zip Code

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I authorize Susan O’Connell to contact my referral source to acknowledge the referral.

Yes                  No

 Client’s Signature­­­­­­­­­­­­­­­________________________________Date_____________________

 

I authorize Susan O’Connell to share information with my insurance company to process my claims.

Client’s Signature________________________________Date_____________________

 

I authorize payment of medical benefits directly to Susan O’Connell.

Client’s Signature________________________________Date__________________­­_­__

 

NOTE: If you fail to cancel an appointment more than 24 hours in advance, you will be charged
             for that appointment.


Please complete and sign this form and bring to your first appointment.

DID YOU FIND ME ON THE INTERNET?   If so, please circle appropriate number:

  1.   Search result (“Susan O’Connell, Therapist, offers Counseling Services…”)
  2.   My Google Ad (“Expert Chicago Counseling. Therapy for Anxiety, Depression…”) under Sponsored Links
  3.  Google Map Listing for one of my offices (“Therapist Susan O’Connell, LCPC”)