Welcome to CBA Chicago. On this page, you will find the necessary forms to begin treatment as well as office location and parking information. To maximize the session time, it is helpful for you to review and complete the New Client Forms beforehand and bring them with you to the first session.
Current clients: To access the Secure Client Portal through Therapy Appointment, click here.
New Client Forms
Client Information Form asks some demographic and contact information questions. Please fill this out and bring it with you to your first session..
Consent Form orients you to CBA Chicago's practice and payment policies, what therapy is about, the risks and benefits of psychological treatment, and confidentiality issues. It is important legally and ethically that you be informed of these issues before we start treatment. Please ask your therapist any questions you still have at any of your sessions. Please print this out, sign it, and bring it with you.
Credit Card Consent Form if you would like to pay for fees or co-pays via credit card, please fill this out and bring it with you to your first session.
HIPAA Notice of Privacy Practices informs you about your privacy rights as required by federal law. It provides important information about legal limits to your confidentiality as a psychotherapy client. Please review this carefully, but you do not need to print it out.
Please also bring your Blue Cross Blue Shield card (if you are using insurance) with you.
Telehealth Forms (if you are doing a telehealth session)
Client Guidelines for Telehealth gives you more information about the technology, logistics, and what to expect from a telehealth session.
Telehealth Consent gives specific information about doing therapy via telehealth. If you are doing a telehealth session, this form also needs your signature.
Location
5100 N Ravenswood Ave., Suites 215, 238 and 245, Chicago, IL 60640. The office is on the west side of the Metra tracks.
PLEASE NOTE: Please use the intercom system at the 5100 entrance and you will be buzzed in. The office is located on the second floor (go up the stairs to the waiting area on the right). You may wait for your therapist in the shared waiting area.
Parking/Transportation: The office is accessible via CTA and Metra. There is free parking in front of the office starting at 10am and street parking.
Fees, Insurance, and Payment
It is important that all new clients check their health benefits before starting treatment. Our full fee for psychotherapy ranges from $180-$200. Please contact your insurance company to see what your mental health benefits are and if you have a co-pay, coinsurance, or an unmet deductible. Please let us know if you have questions about how to do this.
We are in-network with Blue Cross Blue Shield PPO plans, including Blue Choice PPO, and we are considered Out of Network providers for other insurance companies. Often (but not always) clients can still receive benefits with an out of network provider. If you have out of network benefits that you would like to use, we can provide you with a receipt with all the necessary documentation to submit to your insurance company.
Fees and co-pays are due at time of service. Payment can be made via cash, check, or credit card.
When you make an appointment, the time is reserved for you. If you need to cancel or reschedule, please let your therapist know at least 24 hours in advance. Without 24 hours notice, we are typically unable to offer open appointment times to other clients. PLEASE NOTE: There is a $100.00 fee for any missed appointment or late cancellations.
Good Faith Estimate
Health care providers are now required to provide a good faith estimate of the cost of services / charges to clients who are not using insurance or who have out-of-network insurance.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure you save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises, or email Dr. Sara Dittoe Barrett at sara@cbachicago.com.