A pessimist sees
difficulty in every
opportunity, an
optimist sees
opportunity in
every difficulty.
- Sir Winston
Churchill
difficulty in every
opportunity, an
optimist sees
opportunity in
every difficulty.
- Sir Winston
Churchill
Forms and Insurance
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| " Every child deserves the opportunity to reach their full potential" |
Thank you for the opportunity to provide services to your child. If you would like to schedule an
appointment please call one of our two clinics:
10257 W. Lincoln Hwy, Frankfort, IL..........(815) 469-1500...fax (815) 469-1518
1419 Essington, Joliet, IL...........................(815) 729-2160...fax (815) 729-2958
Please be ready to give us all the times your child is available for service, which will expedite the scheduling
process. For general questions we welcome you to call either location.
Part of the intake and assessment process is getting accurate information from you. For your convenience,
you may download the forms prior to your appointment. To view a form, click on the name of the file to
open it (Adobe Acrobat Reader needed - click here to Download). To expedite your first contact with us,
these printable forms are for you to complete and send/fax to the clinic prior to your first visit.
1. Patient Information and Insurance Authorization Form
2. Authorization and Release of Medical Information Form
3. Cancellation Form
4. Consent for Release and Use of Confidential Information Form
- Consent Form Definitions
5. Referral Form
6. Privacy Disclaimer
We currently contract with the following insurance providers. Our participation, allows for the highest
benefit of coverage for our patients. However, this does not guarantee coverage. Please contact your
insurance company regarding your specific benefits.
* Blue Cross/Blue Shield
* Aetna
* St. James PHO
* Silver Cross Managed Care
* Advocate
appointment please call one of our two clinics:
10257 W. Lincoln Hwy, Frankfort, IL..........(815) 469-1500...fax (815) 469-1518
1419 Essington, Joliet, IL...........................(815) 729-2160...fax (815) 729-2958
Please be ready to give us all the times your child is available for service, which will expedite the scheduling
process. For general questions we welcome you to call either location.
Part of the intake and assessment process is getting accurate information from you. For your convenience,
you may download the forms prior to your appointment. To view a form, click on the name of the file to
open it (Adobe Acrobat Reader needed - click here to Download). To expedite your first contact with us,
these printable forms are for you to complete and send/fax to the clinic prior to your first visit.
1. Patient Information and Insurance Authorization Form
2. Authorization and Release of Medical Information Form
3. Cancellation Form
4. Consent for Release and Use of Confidential Information Form
- Consent Form Definitions
5. Referral Form
6. Privacy Disclaimer
We currently contract with the following insurance providers. Our participation, allows for the highest
benefit of coverage for our patients. However, this does not guarantee coverage. Please contact your
insurance company regarding your specific benefits.
* Blue Cross/Blue Shield
* Aetna
* St. James PHO
* Silver Cross Managed Care
* Advocate