Forms

Adult Client Intake Form

Child/Adolescent Intake Form

Insurance Information Form
For BCBS PPO Clients only

Insurance Question Worksheet
Helpful guide to calling your insurance to inquire about your benefits.  This is optional and for your information only.

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

Telehealth Consent Form

HIPPA
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

Contact Information

Office
10024 Skokie Blvd.
Suite 223
Skokie, IL 60077

Phone: 847-483-9701
Email: mindymarxlcsw@reflections-psychotherapy.com

For more information about any of our services, please contact our office:

Phone: 847-483-9701

Email: mindymarxlcsw@reflections-psychotherapy.com

Please contact me to learn more about my services or to schedule a first appointment: 

Phone: 847-483-9701                                             Email: mindymarxlcsw@reflections-psychotherapy.com