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Intake Paperwork

Payment for copay and co-insurance is expected at time of service. Please contact your insurance company and ask your benefit details including copays, deductible, co-insurance, pre-authorization, and procedures covered.

If you are seeking services for your child, this is a reminder that both parents need to be notified of therapy services. Please discuss this with your therapist.

Please print and fill out appropriate paperwork in advance and bring with you unsigned. We will need the General Packet, as well as the specific intake for the patient’s age. We will witness your signature when you arrive for your appointment. Thank you.

General Packet

Adult Intake

Couples Intake

Adolescent Intake Packet-Parent

Adolescent Intake Packet-Teen

Child Intake

Telepsychology Consent Packet

Telepsychology Instructions

No one will be denied access to services due to inability to pay, and there is a discounted/sliding fee schedule available based on family size and income.

Connections Therapy Center will not discriminate in the provision of health care services to an individual:

  1. Because the individual is unable to pay for the health care services;
  2. Because payment for those services would be made under Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP); or
  3. Based upon the individual’s race, color, sex, age, national origin, disability, religion, gender identity or sexual orientation.

Connections Therapy Center

1047 Cannell Court
Rockton, IL 61072

p: 815-957-0115
f: 866-813-6462

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