Dasenbrook & Johnson - Licensed Clinical Professional Counselors

Dasenbrook: 815.877.0399

Home
Starting Counseling
New Clients
Common Conditions
Services
Contact Us

New Client

Welcome to the new client page. Please fill out the New Client Intake Form. Once we have your information we can verify your insurance coverage and advise if you may need a referral or authorization. Please know that while we can assist you with your health insurance, it is your responsibility to know your plan requirements, coverage and payment of all fees. If you are not using health insurance please leave that section blank.

NEW CLIENT INFORMATION:

SELECT A COUNSELOR:

Norman Dasenbrook, LCPC

CLIENT’S NAME:

First Name

Last Name

ADDRESS DETAILS:

Address

State

City

Zip Code

CLIENT’S DETAILS:

Phone Number

Date of Birth

Age

Sex

Male Female

Marital Status

Single Married Divorced Widowed Cohabitating

Emergency Contact:

Relationship

Contact Number:

Medications:

INSURANCE INFORMATION

Insurance Company:

Name Of Insured:

Sex

Male Female

Date of Birth:

Relationship To Insured:

Address:

ID #:

Group#:

Ins. Phone#:

Employer:

Employer Phone:

PLEASE BRING YOUR INSURANCE CARD TO THE FIRST APPOINTMENT

Referred by:

REASON FOR REQUESTING COUNSELING:

** E-mail is not always confidential. If you prefer, you call us or fax the information. **

Questions?

If you have questions feel free to e-mail or call us.

Norman Dasenbrook, LCPC
norm@dasenbrookandjohnson.com
815.877.0399
Fax. 815.877.9382

Nadia Johnson, LCPC
nadia@dasenbrookandjohnson.com
815.282.2462
Fax 815.877.9382

Before your Appointment

Please download the HIPPA and Informed Consent Documents, sign them and bring them to the initial appointment.

Norman Dasenbrook's HIPAA and Informed Consent Document
Nadia Johnson's HIPAA and Informed Consent Document

Home |
Starting Counseling|
Common Conditions|
Services|
Resources|
Contact Us