Affiliated COUNSELING
AND REFERRAL SERVICES (ACRS)
...serving Cary, Crystal
Lake, Barrington, Fox River Grove, Schaumburg, Palatine, Woodstock, Lake in the Hills and McHenry,
IL...
Dr. Michael Shery, Clinical
Psychology
2615 Three Oaks Rd. Ste 2A; Cary, IL
60013
____________________________________________________________________
Doctoral degree: University of Southern California
Referrals accepted from Alexian Brothers, Good
Shepherd, Centegra, Loyola, Northwestern University, University of Chicago and the Mayo
Clinic hospitals and physicians.
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____________________________________________________
Counseling, Therapy
and
Expert Evaluations for:
- ADHD - Alcohol -Substance Abuse -Anger - Fitness for Duty - Disability
-Adoption
____________________________________________________________________
www.carypsychology.com 847 275 8236 (24
Hrs); drmike@carypsychology.com
____________________________________________________________
How to Become a New
Client
The
Easiest Method ... Just go to our appointment book now... and schedule your
appointment>
Make appointment for Cary Office: Therapy and
Counseling
You can fill-out your client information form there and make your
appointment at the same time!
Map to Cary
Office
It couldn't be
easier!
_______________________________________________________________
Or, just
follow these 3 simple steps:
1. Please fill-out the form below.
Copy and paste it into an email
2. When finished, email it to me
at: drmike@carypsychology.com.
3. Then call
me (Dr Shery) at 1-847-275-8236 and I'll schedule an appointment for you on the spot. I'm
looking forward to working with you.
________________________________________________________
Intake Form
Thanks for joining us. We value you as a client and are committed to helping you
achieve your goals.
Issues: Please underline any of the following that apply: anxiety;
depression; family/marriage/relationship problems; child-adolescent behavior; substance
abuse_______ ; work problems; family/marriage; kids; smoking; weight loss; anger management; stress
reduction; chronic illness; auto-work accident/injury; pain; other_____________________
I would benefit from: (please underline) telephone counseling; in-office
counseling-psychotherapy; family counseling; marriage counseling; relaxation training; hypnosis
to___________________;
pain management; adjustment to injury or illness; disability assessment/counseling; substance abuse
treatment; relationship counseling; anger management; depression management; anxiety management;
ADD evaluation; personality testing; stress reduction; other_____________
Patient Name_________________________________ Please underline: Marital
Status: Single Married Other;
Employment: Employed Full Time Student Part-Time
Student; Pt. Email Address_____________________________; May we
send
updates and information there? Y N Pt. Birthday:_______________;
SS#________________________Address_______________________________
Pt relationship to insured: self spouse child other_______; Phone
Numbers:____________________________________
Is there a phone # on your card listed specifically for mental health
services?
If so, please include it:______________________________
If your condition has been caused
by a work injury or auto accident, please include the adjuster’s contact info
here:
_________________________________________________________________
Insured’s SS #_____________________Insured’s Name____________________ Insured’s
Address_____________________________________
Insured’s Phone#______________________________________
Insured’s Policy-Group-FECA#______________________
Insured’s Birthday______________
Employer-School Name____________________________________________
Insurance Plan Name__________________________
Insurance Benefits Verification Phone Number_______________________________
Is There Another Health Benefit Plan?
Yes___________________________No___
Other Insured’s Name____________________________ Other Insured’s Policy or Group
#__________________________
Other Insured’s Birthday:____________________
Employer/School Name________________________
Insurance Plan_______________________________
Insurance Verification Number_____________________
Address to Send Claims___________________________________________________
I acknowledge that my co-pay is payable at each visit with you billing my insurance company
for the balance. If I cancel an appointment in less than 24 hrs in
advance, I agree to pay ½ of the
regular fee to compensate for my therapist and the
office space not being available to others.
I recognize that I will be afforded absolute confidentiality within the parameters prescribed by
law.
I also authorize you to release any information necessary to process my insurance claims and I
request that the resulting benefits be assigned directly to, you, Dr. Michael E Shery as payment
for the services rendered.
Signature:______________________________Date:_______________
Please email this
form by clicking here now: drmike@carypsychology.com
______________________________________________________________
For office use only:
Verify: Deductible__________Satisfied? Y N; Co-Pay__________Session
Limits______________
Claims Address________________________________________________
90801-90806 Pre-Auth Required? Phone #:________________________Y N O; #__ of______;
#__of______; Case #_______________; Auth #________________
Good ‘til_______________96100 Auth Required? Phone #:_____________Y N O; #__ of______;
Y; Deductible______________Co-Pay____________
Tests: 16-PF A16+ 30; ABEL Screen (sx int) AAdol+ 180;
CPI A 13+ 30; Dementia Rating Scale A65-81 60;
Hare Psychopathy Checklist-R (PCL-R) A18+ 150; MAPI (pers
inv) A13-18 60; MACI A13-19 60; Millon Beh Hlth (med
coping) A18+ 45; MMPI-2 A18+ 60; MMPI-A A14-18 60;
NEO Personality-R A3-12 120; Omni Person Inv A18-76 60;
Omni 4 Personality Disorder Inv A18-76 60; PAI A18+ 60;
Personality Research Form A11+ 60; Psychiatric Diagnostic Interview,
revised (PDI-R) A18+ 45; Rotter Incomplete Sentence
Test Achild+ 60; Structured Interview of Reported Sxs
(malingering) A18+ 45; Trauma Sx Inv A18+ 30; Validity
Indicator Profile (malingering) A18-69 60; Wechsler Ab Scale of Intelligence
(IQ) 60
Verify: Blank/Completed Forms; Stamps; Clarifiers: Envelopes
Please email this
form by clicking: drmike@carypsychology.com
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Next, Make your Appointment:
NEXT
STEP: Call Dr. Shery at 1-847-275-8236 and he'll
schedule an appointment for you on the spot.
Map to Cary Office
Or... the easiest way is to just go to our appointment book now... and schedule your own
appointment>
Make appointment for Cary Office: Therapy and
Counseling
____________________________________________________
To read about individual or
marriage counseling>Marriage Counseling and Individual Psychotherapy
To read about telephone
counseling>Telephone
Counseling
>New Patient
Registration
>How to Find the Right Counselor-the FIRST
Time
>Northern Illinois: Drug-Alcohol Treatment Locator
> "
Provider Search:" Find a Counselor Covered by your Insurance
>Counselors-Psychologists in northern Illinois
> MarriageCounseling and Individual
Therapy
> Counseling: Injury and
Car Accident Trauma
>Telephone Counseling
>Articles: Mental Health and Counseling
>Anger Management and
ADHD
>
Depression and Anxiety Articles
> Up-to-the-Minute News
>More Info>www.caryilcounseling.com
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