Hello and welcome to Reflections Psychotherapy. In order to allow us to have the maximum amount of time together for your first appointment, it would be helpful if you could fill out the following paperwork and email it prior to your first appointment, or bring it with you that day. Each form can be downloaded and printed for you to fill out at your convenience.

Adult Client Intake Form

Child/Adolescent Intake Form

Insurance Information Form
For BCBS PPO Clients only

Therapist – Client Service Agreement
First 2 pages for you, 3rd to sign and give to Therapist

Telehealth Consent Form

Attached you will find the HIPPA Privacy Statement for Reflections Psychotherapy, PC. for you to review. You do not need to print this form, unless you would like it to keep for your own records.

No Surprises Act
Attached you will find information about the No Surprises Act for your review

Release of Information Form

If you are uncertain about how to answer any of the questions on these forms, feel free to leave blank and discuss with your therapist, or contact us at (847)483-9701.

Thank you!

Office Locations

Buffalo Grove
355 W. Dundee Road
Suite 214
Buffalo Grove, IL 60089

9711 Skokie Blvd.
Suite H
Skokie, IL 60077

Phone: 847-483-9701
Fax: 847-483-9702