Appointment Info

Yes!
We Are Currently Accepting New Patients!
(Tele-health/Virtual/Online)

New Patient
Intake Procedure:

Call our Main Office number (847-731-3192) to complete a brief Phone Intake with our Staff regarding your circumstances, why you are seeking counseling, and how we can assist you.
Work with us in identifying and obtaining any information, preauthorizations, referrals, and/or agreements for insurance, third-party, or self-pay fees for service.*
Schedule your initial Intake Consultation.
Click on, read, and e-sign the online Initial Consultation E-Form. (Form must be agreed to and submitted to be seen.) (in the box to the right).
All paperwork must be completed completed in advance of scheduling Initial Consultation.

*(While we do accept most insurances, each insurance plan is different and may not cover services provided. Pre-authorizations and/or Statement of Benefits made by an insurance company in establishing rate of payment and patient portion is not binding and is subject to their review. As such, you may be responsible for paying a greater portion than initially indicated should your insurance or third-party payor deny or adjust your claim).

**Please Note:
We do NOT accept any form of Medicaid, Medicare, or State-aid.

Dr. Rhodes is licensed in the states of Illinois, North Carolina, and Wisconsin. Patients from any other state can only be seen via Self-pay and are classified as Pastoral Counseling.

Thank you for your understanding.

Intake Consultation E-Form

* Indicates required field

I understand that all paperwork and contracts must be completed in advance of my initial appointment. I understand I will not be able to be seen if these are not completed in their entirety. I understand that there is a fee for this scheduled appointment. Should I fail to keep this appointment without canceling at least 24-hours in advance I will be charged a No Show Fee. Should I cancel this appointment with less than 24-hours notice I will be charged a Late Cancel Fee. I understand that my identified fee is based upon the information I have provided to Love-light. Should any of this information be found to be different from what was disclosed regardless of reason, I understand I will be responsible for the adjusted fee, up to and including the full Fee. I understand any pre-authorization or statement of benefits made by my insurance company in establishing their rate of payment and my portion is not binding and is subject to their review. As such, I understand that I may be solely responsible for paying for a greater portion of the fee than initially indicated (including the full Fee), should my insurance deny or adjust the claim for any reason. I understand that I am solely responsible for the entire Fee, including any portion of the fee written-off by the Sliding Fee should my financial information be found to be inaccurate for any reason or for any portion not paid by my insurance or third-party payor regardless of reason or circumstances. I understand and agree to the above terms. *

Yes

Email *

Patient/Guardian's Name *

First

Last

Submit

Yes!We Are Currently Accepting New Patients!​ (Tele-health/Virtual/Online)

Intake Consultation E-Form

Yes!
We Are Currently Accepting New Patients!
(Tele-health/Virtual/Online)