• New Client Intake Form

    Please keep this information for your records:

    Welcome to KM Institute LLC! We appreciate your decision to choose us, and we look forward to serving you in a specialized manner that is custom created for your needs.

    KM Institute LLC is dedicated to providing high quality clinical services to the community. As part of these services, we provide resources of 24 hour crisis lines to access as our practice does not render 24 hour availability. In the event of an emergency, please call 911.

    Kane County Crisis Line of the Fox Valley (24 hour): 630-966-9393

    DuPage County Crisis Line (24 hour): 630-627-1700

    Client Information

    Referral Source: Please share how you found us. (circle one):
    Friend Family member Website Medical provider
    If other, please specify:

    Insurance Information

    CLIENTS THAT ARE MINORS:

    KM Institute LLC renders services to minors with the consent of both parents (as applicable). KM Institute LLC may request official documentation outlining parenting agreement paperwork if a discrepancy exists regarding the parents/guardians consent for services rendered to the minor.

    CONSENT FOR SERVICES:

    I consent to the evaluation and treatment process with KM Institute LLC, and I understand that this process may include myself, my spouse, my children, and/or other family members as applicable. I understand that I have the right to withdraw from treatment at any time. If I choose to cease treatment, I understand that I will remain responsible for paying for the services I have received.

    CONFIDENTIALITY:

    I am aware that KM Institute LLC may request personal information in order to optimize treatment outcomes, and that these inquiries may include insurance information. I am aware that an agent of my insurance company or other third-party payers may be given information about the type, cost, dates, and provider of any services I receive in order to maximize coverage.

    As a client and/or parent/guardian of a minor client, I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information.

    KM Institute LLC is dedicated to maintaining the highest level of confidentiality at all times.
    Therefore, please be aware that email communication is not completely secure, and that any information that may be stolen is not the responsibility of KM Institute LLC. My initials represent my understanding of risks associated with email communication.

    Financial Policies:

    Failed Appointment/Late Cancelation Policy: Appointments will be scheduled at a time mutually acceptable to both the client and the therapist at KM Institute LLC. A 24-hour advance notice of cancellation is required, except in cases of extreme emergency. Appointments cancelled with less than 24 hours notice will result in a charge of $75.00 to your credit card on file. Should a late cancellation or no show to an appointment fall on a holiday, 150.00 will be charged.

    Fee Policy: I understand that if payment for services I receive is not made, the therapist may stop services until the balance is paid. I understand that KM Institute LLC will pursue reditors Protection Service Inc collection agency as necessary for any balance exceeding 60 days past the date of service of the balance due. If a check is returned for insufficient funds, I agree to be responsible for any bank fees assessed, and that an alternative method of payment will be required. If a credit card is declined twice, cash or check payments are required.
    All copays/payments are due at the time of service.

    File Request Policy: File requests for other providers must be submitted in writing with a one week notice. Fees for printing and mailing files is a flat rate of $50.00.

    Adjunct Service Policy: Clients may request formal treatment letters for schools, other healthcare providers, etc. Adjunct service requests must be submitted with a one week notice, and the flat rate is $20.00.

    Insurance:

    I understand that I am solely responsible for out of pocket costs that may be incurred, and that the benefits information that KM Institute LLC may relay to me from my provider is not a guarantee of coverage or benefits. I authorize the release of any medical or other information necessary to process my insurance claim. I understand that billing will be submitted to insurance under the provider I see, or the supervisor of that provider.

    Consent to Release/Exchange Information

    Please complete this form if there is individual/agency with whom you would like your clinician to be able to exchange information. Please note that completion of this form is not a requirement for treatment. Please make copies of this form if you would like to consent to multiple parties incorporated in coordination of care.

    hereby give consent to KM Institute LLC to

    This release/exchange is valid until the end of treatment. I understand that I have the right to revoke this consent at any time.

    Emergency Contact

    Please complete this form for an emergency contact you would like your clinician to notify should one ever be necessary. Please note that completion of this form is not a requirement for treatment with the exception of minors under age 18.

    hereby give consent to KM Institute LLC to

    This release/exchange is valid until the end of treatment. I understand that I have the right to revoke this consent at any time.

    Credit Card Policy

    All Clients are required to keep a credit card on file with KM Institute LLC in order to receive services. If you wish to pay by check or cash, those forms of payment are also accepted.
    I understand that by signing below, I am authorizing KM Institute LLC to charge my credit card for services rendered. These balances may include unpaid co-pays, co-insurance amounts,
    deductibles, and/or charges for missed/late cancelled appointments. KM Institute LLC will contact me if my card is declined or expired to update this information.

    Please be sure to complete all sections:

    Visa, MasterCard, AmEx, or Discover (circle one, flex spending accepted)