2025 MCC Intake Packet- Parents

Guardian Information/ Primary Emergency Contact

Please provide us with the contact information for the client's guardian.
Guardian's Name*

First NameLast Name
Guardian's Phone Number*
Guardian's Relationship to Client (Example- Mother, Sister, etc.)*
Guardian's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attach a state issued ID for the guardian.

Cancelof

Second Parent and/or Emergency Contact

MCC recommends having a second emergency contact on file. This may be a second parent/guardian, a family member that will often drive them to therapy, etc.
Secondary Emergency Contact's Name

First NameLast Name
Secondary Emergency Contact's Phone Number
Secondary Emergency Contact's Relationship to Client (Example- Mother, Sister, etc.)
Secondary Emergency Contact's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In what way(s) would you expect this individual to be involved in your youth's therapy experience?

Support Person

All adults accompanying the client to sessions must have a release of information competed for them. Is there anyone else that may accompany your child to sessions or that may be involved in therapy for any reason? If there are any additional people, please contact the office.
Support Person's Name

First NameLast Name
Support Person's Phone Number
Support Person's Relationship to Client (Example- Mother, Sister, etc.)
Support Person's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In what way(s) would you expect this individual to be involved in your youth's therapy experience?
Is there anyone else that may be involved in your youth's treatment, transportation, etc?
Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Primary Insurance Information

If any information is not available on your card, enter N/A.
Primary Insurance Company*
Policy Number/ RIN Number*
Group Number*
Primary Insurance Phone Number (Provider or Claims - On the Back of the Card)*
Is the Client the Subscriber on this policy? (The primary person on this policy is the subscriber. If the policy is through your job, you are the subscriber. If it is through your spouse/parent's work, they are the subscriber.)*

YesNo
Subscriber's Name*

First NameLast Name
Subscriber's Date of Birth*

MonthDayYear
Date
Subscriber's Relationship to Client*
Does the subscriber live in the same home as the client?*

YesNo
Subscriber's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the client covered under more than one insurance policy? (All insurance plans must be disclosed to MCC.)*

YesNo

Secondary Insurance Information
Secondary Insurance Company*
Secondary Policy Number/ RIN Number*
Secondary Group Number*
Secondary Insurance Phone Number (Provider or Claims - On the Back of the Card)*
Is the Client the Subscriber on this policy? (The primary person on this policy is the subscriber. If the policy is through your job, you are the subscriber. If it is through your spouse/parent's work, they are the subscriber.)*

YesNo
Subscriber's Name*

First NameLast Name
Subscriber's Date of Birth*

MonthDayYear
Date
Subscriber's Relationship to Client*
Does the subscriber live in the same home as the client?*

YesNo
Subscriber's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social History

FAMILY OF ORIGIN
Birth Location: City, State*
Who are your youth's primary caretaker(s)? (Select all that apply.)*

Both biological parentsAdoptive parentsSingle motherSingle fatherGrandmotherGrandfatherBoth grandparentsFoster care systemAdoptive parentsOther
Please provide information on everyone living in your home.*
Describe the relationship between the youth and the adults in the home. *
Describe the relationship between the youth and other youth in the home.*
Describe discipline in your home.*
Please describe how the adults in your household usually interact with one another. This might include how conflict is handled, how often there is yelling or tension, and whether the environment feels calm, stressful, or something else.*

DEVELOPMENTAL HISTORY
Are you aware of any concerns/issues that occurred during your youth's gestational period? (Such as being premature, mother had complications, etc.)*

YesNo
Are you aware of any concerns/issues that occurred during your youth's early childhood/school years? (May include things such as needing early childhood interventions, attending special education classes, having a learning disability, having a significant illness, etc.)*

YesNo
If yes to the above questions, please explain.
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ACADEMIC HISTORY
Current Grade in School:*
Name of School Attending:*
Please tell us about your youth’s current experience at school, including how they’re doing socially, whether they have close friendships, if they’ve experienced bullying or exclusion, and any signs of anxiety, sadness, or stress related to school.*
Has your youth ever been suspended, expelled, frequently in trouble at school, had conflicts with teachers or authority figures, or regularly skipped or avoided school?*
Has your youth experienced anything at school that felt traumatic or deeply upsetting, or are there school-related events that still seem to affect them today?*
How are your youth’s grades overall, and have you noticed any recent changes — either improving or declining — in their academic performance?*

SUPPORT SYSTEM
Does your youth have a support system? Who are the people that support them the most?*
Does your youth have people in their life that you would consider unsupportive or toxic? Please describe.*
Is your youth in a romantic relationship? What is your impression of that relationship? Does it appear healthy?*

FAMILY MENTAL HEALTH HISTORY
Do any other family members have any mental health concerns? If so, please tell us about them. *

CLIENT'S MENTAL HEALTH HISTORY
Please share any mental health diagnoses your child has received from a doctor, therapist, or other mental health professional. If you're unsure of the exact diagnosis or age, feel free to describe what was going on at the time.*
Has your youth ever received treatment for a mental health condition? If so, please tell us about it. This includes outpatient therapy, medication management, substance use treatment, residential programs, or psychiatric hospitalizations. *
Tell us about any other mental health providers that your youth is currently seeing.*
Psychotropic Medications: Please tell us about any medications your youth is taking for their mental health.*
Has your youth ever expressed any thoughts or actions of harming themselves? If so, please tell us about them. *

CULTURAL IDENTITY & TREATMENT CONSIDERATIONS
Are there any cultural beliefs, values, or experiences that you think should be considered in your youth's therapy?*
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COORDINATION OF CARE
Clients often want us to be in contact with outside providers in order to provide them with the best care possible. These people may be doctors, someone at their place of employment, lawyers, probation officers, school providers, etc. Is there anyone that you would like us to be in contact with? If so, please provide us with their name, relationship to you, phone number, fax number, and business address. We will complete a release of information and send it to you through your client portal.*

Thank you for completing your intake questionnaire.

The next step is to review and sign the required consent forms. These help us ensure that you’re informed about your rights, privacy, and how therapy works at our practice. Please take a few moments to read through each form carefully and let us know if you have any questions.

2025 MCC Intake Consents- Parents
Thank you for taking the time to complete the intake process — we know it can be a bit overwhelming. We truly appreciate your effort and care. These final consent forms ensure we have everything we need to move forward with your child’s services.

2025 MCC Informed Consent for Mental Health Services & Practice Policies
Informed Consent for Mental Health Services

This document provides you with important information regarding your mental health treatment including costs, privacy policies, limits of service, etcetera. Please have each adult participating in therapy read & sign a separate electronic or paper form. If you have any questions regarding its content or our policies, please immediately ask your clinician or someone on our administrative team. The informed consent for mental health services must be signed by the client and or guardian of the client to receive services and will be reviewed and resigned annually.

The Mental Health Process

Milestones Counseling Center PLLC is a team where professionals of diverse training and backgrounds collaborate to help you in reaching your stated mental health goals. Our goal is to serve as your partner in the therapeutic process. As such, it is crucial that you provide ongoing feedback to our team regarding the process, your changing needs, and the effectiveness of our services. You always have the right to disagree with your clinicians’ recommendations and refuse any recommendations that are made.

Due to the varying nature and severity of presenting issues as well as unique personality of each client we are unable to predict the length of your therapy or guarantee specific outcomes. We believe it can take months or years for clients to reach their goals and that consistent appointment attendance is crucial to that process.

Termination, or the process of ending your mental health treatment with our practice, is a collaborative process between you and your clinician. When you and your clinician feel that your goals have been reached, we will encourage you to decrease the frequency of care to a minimum of one appointment every three to six months. If you decide to completely end care your clinician will still encourage you to schedule a follow up appointment for some point in the next year to ensure that you maintain your therapeutic progress without needing to restart regular therapy.

If you ever feel like your therapist is not a good fit for your needs, we encourage you to ask that therapist for a referral or contact our scheduling team (708-880-7747). You can also e-mail our scheduling team at admin@milestonescounselingcenter.com.

As a client of Milestones Counseling Center PLLC, you have the right to service is free from abuse, financial or other exploitation, retaliation, humiliation, or neglect. If you believe you are experiencing one of these things, even if you are not fully certain, please contact us at info@milestonescounselingcenter.com. If you ever have any complaints about your therapist or our practice, please do not hesitate to contact our practice owner, Michelle Adams, at 708 880 7747 x2, or at info@milestonescounselingcenter.com.

Contacting Employees

You may find the need to contact your clinician, or another employee, in-between sessions. Please note that we are often not available to answer the phone. All employees aim to respond to contact attempts within 24 hours.

Communicating via the client portal is, not only he most secure, but usually the most efficient. Employees can respond 24/7 and can often respond in-between therapy sessions. This is not something that can be done with phone calls.

You may contact Milestones Counseling Center PLLC employees in any of the following ways:
- Log into your client portal and use the messaging feature. This is the most secure and efficient way of communicating with employees.
- E-mail us at admin at milestonescounselingcenter.com
Medication Management

To better meet the mental health needs of our clients, our clinicians will often recommend medication management services from independent physicians or nurses outside of our practice. By your request, your clinician may communicate with this individual to help coordinate care and help you reach your goals. A release of information must be completed for this individual before any contact can be made. In addition, you may always research your own medication management services by contacting your insurance company directly.

Psychological Testing

Currently Milestones Counseling Center PLLC does not do psychological testing. If you are interested in psychological testing in addition to therapy services, please notify your clinician to obtain referrals. You may also contact your insurance company’s customer service center.

Client Emergencies

Milestones Counseling Center PLLC does not currently offer on call, after hours, or emergency services. We are solely an outpatient clinic providing services by appointment only. In the event of a medical emergency (including side effects from prescribed medications) or an emergency involving a threat to your safety or the safety of others, please call 911, go to your nearest emergency room, or call 988 for the mental health hotline.

Our clinicians do not travel to see clients or make house calls. All meetings with our clinicians must take place in our established place of business or via telehealth, unless previously scheduled to occur at another location and approved by Milestones Counseling Center PLLC practice owner.

Client Communications, Public Contact, and Social Media

To facilitate communication, we require all clients provide us with a valid home address, telephone number and e-mail that we may use to contact you. We encourage you to avoid providing contact information associated with your place of employment to help protect your privacy, as Milestones Counseling Center PLLC is not liable for breaches of privacy associated with the contact information you provide.

E-mail communication will be sent through an encrypted e-mail whenever possible but some systems in use may not have this option.

By signing the last page of this document, you give our clinical and administrative personnel authorization to contact you for scheduling and billing purposes at the addresses provided. By signing this client agreement, you also acknowledge and give permission for Milestones Counseling Center PLLC to include private health information in these communications.

Our team wishes to be sensitive to your confidentiality in public settings. If we encounter you in public, we will do our best to avoid contact or conversation with you and encourage you to do the same. At no point will we discuss the details of your mental health treatment outside of offices.

All of Milestones Counseling Center PLLC staff and clinicians are prohibited from engaging in anything besides a therapeutic relationship with our clients. This includes, but is not limited to, accepting relationship requests on social media, exchanging gifts, entering business and personal relationships with clients, or similar activities with close or immediate family members of clients.

Fees and Insurance Policies (subject to change without notice)

Our standard fees for all insurance billing, are your payers’ allowable amount or the amounts listed below, whichever is less. In most cases your responsibility will be far less than the either of those amounts and will be limited to your insurance copay if applicable.

Clients with insurance, but not wishing to utilize their insurance, may request a negotiated “cash discount” rate that is less than the ones below and reflect our cost savings associated with paying your bill in full at the time services are rendered. This “cash discount” will be equal to the negotiated rate of your insurance plan. Offering a rate lower than this would put us in breach of the contracts we hold with your insurance company.

The clients needing pro bono or low clock cost therapy services, these are available upon request through Milestones Counseling Center PLLC’s graduate level interns. These services are exempt from therapy rates below. A limited number of these spaces are available. Fees for records, court appearances, etcetera still apply.

$175- Initial individual counseling appointment and family therapy

$150- each subsequent 55-minute counseling/therapy session

$99- Late cancel (less than 24 hours), No shows, Late Arrival/Early Departures (10 minutes)

$100- written treatment summary (1 to 2 pages)

$50- group therapy (lasting 60 to 90 minutes) for unrelated parties

$25- insufficient funds/bounced check fees

$25/15 minutes- Any phone conversation over 7 minutes will be charged at a prorated fee based on $100/hour. This will be billed in 15-minute increments. Phone calls are not covered by your insurance company.

$25/15 minutes- Any paperwork completion over 7 minutes will be charged at a prorated fee based on $100/hour. This will be billed in 15-minute increments. Paperwork completion is not covered by your insurance company.

In accordance with the standards set by the Illinois medical board, fees for all records releases are as follows:

$15 labor fee on all records, plus $1.00 per page for the first 25 pages, then $0.79 for pages 26-50, then $0.39 for each additional page.

If records are mailed, client will be responsible for all postage. Records may be picked up at a mutually convenient time at Milestones Counseling Center PLLC’s Crete, IL office for no additional cost. In addition, there will be a $50 rush fee assessed for anyone wanting documents in less than our standard 5 to 10 business days. Cost of records is payable prior to the pickup or mailing of requested records.

If a third-party request records on your behalf, you will be responsible for paying the records fee if payment is not received from them within 60 days of the release. If they pay a maximum fee or failed to remit our full fee, the difference will also be charged to your card on file. Records may be requested by sending an e-mail to info@milestonescounselingcenter.com.

Sessions that last longer than their allotted time, as well as Telehealth sessions, will be prorated into 15-minute increments and charged to your credit card on file (if required). Counseling or therapy sessions involving crises or technical complexity may be billed to insurance at higher rates than those listed above.

In the event a client request that any member of our staff complete paperwork of any kind on their behalf (FMLA, disability, etcetera), the client will be charged their clinicians hourly fee, prorated into 15-minute increments. Completion of such paperwork is not covered by insurance and will be billed at the clinician’s hourly rate to the credit card a client placed on file (if required).

Completion of Legal and Disability Forms

Milestones Counseling Center PLLC clinicians and staff do not provide evaluations regarding the scope, nature, duration, or accommodations related to a disability or other medical conditions. Instead, our clinicians will only provide their diagnosis and clinical observations of their clients. Further, no such evaluations will be completed by our clinicians until a minimum of five clinical visits have occurred. Questions regarding the scope, nature, duration, severity, or accommodations related with any medical or mental health condition will be answered with “No opinion- outside the clinician’s scope of practice”.

Milestones Counseling Center PLLC and its clinicians will not provide letters recommending emotional support animals, medical marijuana, or any matters regarding employment, immigration, or fitness to serve matters.

Collection of Fees

Copays, coinsurance, and session fees for non-insurance clients are due at the time services are rendered. The credit or debit card you have placed on file, if required, will be charged the day of your scheduled session. If your card is declined, our office will continue to attempt to process your card including partial amounts at our discretion for up to 180 days after your appointment. We are not responsible for fees associated with the bank account, including overdraft fees, or delayed processing of your credit card.

In the event the client contests a valid charge resulting in a reversal or chargeback initiated by their card issuer, Milestone Counseling Center PLLC will assess a clients account $50 to cover the cost charged by our credit card processor and the additional labor involved with collecting their outstanding balance.

Failure to pay any fees within 60 days of the date of service will result in your private information being turned over to the law firm or collection agency of our choice for collection actions, including the possible filing of a public lawsuit for collections. This may result in the disclosure of some aspects of your private health information. Fees associated with collections will be added to the balance you owe to our practice.

Timeliness / Cancellation / No Show Fee

Due to the nature of our business, it is essential that sessions start and end on time. We appreciate your cooperation in arriving on time for your appointments. While therapists make all attempts to arrive on time, we do, on occasion, run over time to provide the best care for the client before you. Please allow your therapist 10 minutes past your scheduled appointment to arrive. If your therapist’s timeliness becomes an issue, please contact Michelle at info@milestonescounselingcenter.com.

All clients will be charged a $99 fee per therapy hour that they fail to show up for, cancel with less than 24 business hours’ notice, or show up more than ten minutes late or leave more than ten minutes early. This is due to our inability to properly bill insurance for the time you reserve that cannot be recouped.

Monday appointments are required to be cancelled / rescheduled by the Friday prior to the appointment.

This fee is charged regardless of the reason for your no show, later arrival, late cancellation (including illness, family emergency, vehicle difficulties etcetera. This fee is also charged to non-insurance clients whose agreed session fee is at least $99 per hour.

Any non-insurance clients with a negotiated rate of less than $99 dollars per booked hour of therapy will be charged their entire session rate for no shows or late cancellations.

This fee will be charged to your credit card on file within 24 hours and is not covered by your insurance provider or EAP.

Please do not rely on voicemails to cancel your session. You may cancel your appointment in any of the following ways:
- Cancel during a prior session
- Log into your client portal and cancel your appointment before 24 hours.
- Message your clinician, Michelle, or Melissa in the client portal
- Text the office @ 708-880-7747
- E-mail us at admin at milestonescounselingcenter.com
The $99 fee will be charged unless specifically prohibited by a third-party payer (insurance company, government program, etcetera).

Inclement Weather Policies

Snow/ice days- Cancellation / no show fee is only waived if Crete-Monee School District 201-U is closed for the day. Telehealth is always a possibility if clients do not want to leave home, but schools are still in session.

Tornado sirens- If a tornado siren goes off during a session, please end the session and go to the safest place near you. You are welcome to move to a safe space with a Milestones Counseling Center PLLC clinician but are always free to leave the office if you so choose.

No Unaccompanied Minors

Children under age 14 may not be left unattended in our waiting areas. If our therapist realizes that a minor is unaccompanied, they will terminate the session and apply the no show fee. Additionally, children under 14 that are receiving therapy are required to have a parent or guardian seated in the waiting room at all times. Failure to remain on site may result in a call to DCFS. Waiting outside or in the car is not sufficient.

Legal Retainer

Milestones Counseling Center PLLC does not get involved in court proceedings. The agency will not provide documentation, aside from a treatment summary, for court purposes. If a clinician is subpoenaed, by a judge, to attend court, the client and/or their guardian is responsible to pay the court fees.

By signing this document, you agree in advance to pay our $2500 legal retainer fee (per day, per staff person) should we be asked to testify in any type of court proceeding. This includes, but is not limited to, any type of court trials (include divorce or custody cases), depositions, mediations, etcetera. You agree to pay this fee even if another attorney, without your authorization, subpoenas any of our staff regarding your records.

Additional court related fees, not included in the daily retainer: Client is responsible for $300/hour for preparation time, any incurred legal costs for consultation required to prepare for court, and any additional fees that may be incurred due to the court participation.

This fee must be paid prior to our appearance in court and will be billed to your credit card if one is on file. If a credit card is not on file payment must be submitted in full by credit or debit card, check, or cashier’s check. Failure to pay this fee will result in our normal collection procedures. Unless specifically contracted to do so, in writing prior to your first appointment, Milestones Counseling Center PLLC’s clinical staff will not make custody recommendations regarding children, even if we have provided therapy service to all parties involved in the divorce.

Please note that provisionally licensed clinicians may require, per Milestones Counseling Center PLLC, supervisory support for any and/or all these tasks. If that support is required, fees will be doubled.

Recording Fee

Milestones Counseling Center PLLC strictly prohibits audio or video recording of any therapy or other interaction without all parties expressed written consent. By signing this document, you also agree to pay a fee of $2500 for each session in which you record all or part of the session, without Milestones Counseling Center PLLC's expressed written consent.

In-Network Insurance Billing

Not every clinician at Milestones Counseling Center PLLC works with every insurance company. If one of our providers can provide you with in network care and you wish to use that coverage, we will collect your estimated copay or cost share the day of the session. This fee may be collected prior to your appointment.

It is your responsibility to know your insurance coverage and notify Milestones Counseling Center PLLC of any changes to your insurance, coverage, or policy. If your insurance coverage has changed, you must notify Milestones Counseling Center PLLC prior to your next visit. Any services provided that are not covered by your insurance company are your financial responsibility and are subject to our standard collection procedures.

Out of Network Insurance Billing

If your clinician is not contracted with your insurance company, your insurance is considered “Out of Network.” This means that it may be subject to a different set of deductibles, copay formulas, and limits on coverage and we cannot guarantee your insurer will reimburse you for your care. Clients wishing to use out of network insurance coverage must pay their therapist negotiated cash discount rate (written in at the beginning of the fees section of this document) at the time of service.

We do not submit claims on an out of network basis for our clients. If you want your claims submitted on an out of network basis, you need to contact our billing coordinator at info@milestonescounselingcenter.com and request a super bill that you can personally submit to your insurer.

If you’re out of network insurance coverage fails to cover your care, you will be held liable for our standard rate for cash pay clients.

Fees Not Covered by Insurance

Insurance companies will not cover mental health services where a valid diagnostic code is not provided and or there is no evidence of medical necessity. Milestones Counseling Center PLLC defines medical necessity as a condition that impairs your relational, vocational, emotional, physical, or spiritual functioning. For families and coupling couples seeking counseling, at least one individual must be assigned an individual diagnosis code and treatment must be appropriately focused on treating the individual’s diagnosis. Additionally, insurance companies do not cover no show fees, cancellation fees, record fees, or fees associated with our legal retainer. These fees are your sole responsibility.

Confidentiality and Privacy

As part of providing therapeutic services, various Milestones Counseling Center PLLC staff beyond your clinician will have access to your private information as needed to perform their job duties. Your rights to privacy and explanations of how your information are used are more fully explained in a separate document entitled Notice of Privacy Practices. If you have not received this document or would like another copy you can request one by emailing us at admin@milestonescounselingcenter.com

Confidentiality and Complaints

By signing this agreement, you give Milestones Counseling Center PLLC permission to break confidentiality in order to properly address or answer any complaints or lawsuits you bring against our practice, or any individual staff member or contractor associated with our practice, whether you bring them in a public or regulatory setting.

Release of Records and Documentation

Milestones Counseling Center PLLC has a very strict records release policy, even if documentation or records are being released directly to you the client. In all case cases, written permission is required to release any written documentation of any kind or to communicate with any parties besides those under our care. Further, the identities of all parties authorizing release must be verified by one of our staff using your government issued photo identification or by providing us with a notarized copy of our release form. If you participate in marital or family therapy, Milestones Counseling Center PLLC will not disclose confidential information about your treatment to unrelated parties, unless all adults who participated in therapy with you provide their written authorization for release of said information. Release of records may take up to 10 business days from the time we received a signed consent form and are subject to the fees outlined above. If needed sooner than five to 10 days, records are subject to an additional $50 fee for rush service. All fees and postage will be billed to the credit card on file, if required, on the date the records are released or mailed. Records may be requested by sending an e-mail to info@milestonescounselingcenter.com.

Your Privacy and 3rd Party Payers

By signing this form, you consent that all submissions for reimbursement sent to insurance companies, employment assistance plans, and other third parties may include private health information such as your diagnosis, identifying information, dates of service, and amounts paid to our practice. If a family member or other acquaintance agrees to pay for your services, we reserved the right to communicate to them about session attendance, no shows / cancellation fees and the expected duration and effectiveness of therapy.

Call Recording

All phone calls to our administrative staff and clinicians may be recorded and be archived for up to six months for quality control and training purposes.

Supervision and Consultation

All clinicians at Milestones Counseling Center PLLC are subject to the full supervision of our clinical directors. This means that your case and private health information may be discussed with your clinician supervisory chain of command or supervision group. Additionally, notes for every session performed by unlicensed graduate interns and provisionally licensed clinicians, are reviewed by their clinical supervisor. Graduate level interns may also discuss cases in their class at their university as part of their graduate training program. This discussion will take place with as little identifying information as possible.

From time to time, our clinicians will also seek outside consultation from other industry professionals regarding their clients. Additionally, our therapist may use anecdotes from therapy as part of writing, speaking, teaching or being interviewed in public settings. In these instances, all reasonable efforts will be made to ensure client confidentiality.

No Secrets Policy

When working with multiple persons within the same family, Milestones Counseling Center PLLC adheres to a no secrets policy. This means that we cannot and will not guarantee confidentiality between the multiple parties engaged in marital, couples, or family therapy. Further, our clinicians reserve the right to break confidentiality when they encounter information that any party involved in treatment might feel betrayed or aligned against if the information remains secret. Your clinician may attempt to notify you prior to disclosing material facts to another adult involved in conjoint therapy with you but does not guarantee this.

Treatment of Minors and Confidentiality

Communications between clinicians and clients who are minors (under the age of 18) are confidential. However, in the exercise of their professional judgment, your clinician may discuss the treatment progress of a minor client with the parent or legal guardian as is beneficial to the child. We strongly discourage parents from using their right to a child’s medical records to violate this confidentiality. We believe it destroys a child’s trust in their clinician and the mental health process.

If you are a minor, your parents/guardians may be legally entitled to some information about your therapy. We will discuss with you and your guardians what information is appropriate for them to receive and which issues are more appropriately kept confidential.

Right to Respond to Complaints, Reviews, and Media

If you exercise your right to create an online review, file a complaint with any regulatory body, or engage in commentary in the media about our practice, clinicians, or your treatment, you also waive your right to confidentiality. By signing this agreement, you give Milestones Counseling Center PLLC permission to respond publicly and privately to any such complaints while protecting its reputation, defending its ethics, or clarifying facts related to your treatment.

Tobacco, Alcohol, and Illegal Substance Usage

Policy- smoking or vaping of any kind (tobacco, marijuana, etcetera), possession or consumption of alcohol, or use of any other illicit, illegal, or mind-altering substance, is strictly prohibited by both staff and clients within our facilities.

Procedure for Tobacco, Alcohol, and Illegal Substance Usage

In the event that an individual engages in any of these behaviors, they will be asked immediately to cease, and a critical incident form will be completed and added to the client or employees file for management review and action. Failure to cease and or repeat violations may result in termination of services or dismissal from employment.

If a client arrives to session and use is suspected by the clinician, the session will be ended immediately, and the client will be charged $99 for an early terminated session. In addition, if the clinician feels that the client is unable to safely drive home, the clinician has the right to notify the local police department. You agree to waiving your confidentiality.

Lost and Found Policy

Milestones Counseling Center PLLC is not responsible for the safety and security of items brought by clients, staff, and visitors onto its premises. If an item is left behind by a client, staff or visitor and is found by one of our staff, we will make our best attempt to secure those items in the office to be claimed later. Illegal or illicit items will be disposed or turned over to law enforcement, as safety dictates. Medications left behind will be transported to the nearest pharmacy and are turned over to law enforcement.

Mandated Reporting

Milestones Counseling Center PLLC may, without notice, break client confidentiality and contact the appropriate authorities with all pertinent information when we suspect:
- Child, elder, or dependent adult abuse is revealed about any party, including those not in therapy.
- A client poses a serious physical threat to themselves or others.
Additionally, by signing this document, you give Milestones Counseling Center PLLC permission to release information when ordered by a judge or court of law under threat of sanction to our practice or staff.

Use of Third-party Software, Applications, and Electronic Communication

Milestones Counseling Center PLLC uses several software, web-based, and electronic applications created and administered by third party providers. These include but are not limited to Simple Practice, iPlum phone and fax service, Google Gmail, and business applications, Paubox, and various cell phone providers. Additionally, third party applications may be implemented by our practice without any additional disclosure to you as the client at any point in the future.

While Milestones Counseling Center PLLC has secured a business associate agreement from each of these service providers, we cannot ultimately guarantee their compliance with HIPAA and other regulations. As part of signing this document and receiving service from us, you exempt Milestones Counseling Center PLLC from liability or blame for any privacy violations that occur due to any action on the part of these vendors.

Agreement to Mediation

All complaints and disputes, except for collection actions initiated by Milestones Counseling Center PLLC, will be handled through a certified mediator. The mediator will be chosen by Milestones Counseling Center PLLC and paid for by the party initiating the complaint.

Technology Assisted Counseling / Online Counseling / Telehealth

1. Potential risks and concerns with phone and video counseling

Due to certain limitations, technology assistant counseling should be used only when face to face counseling is not available or practical given the client’s life circumstances. Specifically, you as the client should be aware of the following limitations associated with counseling over the phone, e-mail, or video counseling: Possible misunderstandings due to the lack of nonverbal cues normally present with in-person counseling. Technology assisted counseling is prone to possible misunderstandings between the therapist and client. If you’re having trouble understanding your therapist’s communications or feel misunderstood, you should immediately tell your therapist or e-mail them these thoughts after your session.

2. Turnaround time

Technology assisted counseling involves a longer lag time between when you communicate with your therapist and when he or she communicates back. Our counselors make every effort to respond to your communications, within a 12-to-24-hour period of your request. It is important to realize that the use of these services does not mean that your therapist is on call or available to you in a crisis or emergency situation. If such a situation arises, you should call 911, go to your nearest hospital emergency room, or contact 988.

3. By signing this agreement, you acknowledge that Milestones Counseling Center PLLC is not your emergency care provider and exonerate them from liability arising from delayed responses.

4. Privacy breaches

Technology assisted counseling utilizes many outside resources and companies (internet and software providers, Public Utilities, etcetera). All these entities are prone to their own security risks. By signing this agreement, you agree to evaluate and establish your own technological safeguards (strong passwords, secure networks, virus protection) and indemnify Milestones Counseling Center PLLC for any blame or liability associated with the hardware, software and third-party technology providers use select.

5. Safeguards employed by Milestones Counseling Center PLLC

Milestones Counseling Center PLLC uses Simple Practice for video-based communications. All personal health information acquired and stored by Milestones Counseling Center PLLC is encrypted and utilizes HIPAA compliant cloud-based services. Please discuss any such concerns with your counselor early in your first session to develop strategies to limit risk.

6. Records and recordings

In addition to our normal clinical records, Milestones Counseling Center PLLC maintains records of when online counseling services were provided and to who. NO AUDIO OR VIDEO RECORDING of any kind is permitted by either the client or the therapist. Without expressed, written consent by both all parties involved. By signing this agreement, you agreed to pay $2500 per session that you record without our permission.

7. Emergency contact services

If there is ever a disruption of services on the Internet, then the client will need to notify our main office at 708-880-7747.

By signing this document, I certify that I understand the limitations of technology assisted counseling/telehealth and consent to the use of these measures, if agreed upon with my clinician.

Progress Note Taking Software

Milestones Counseling Center PLLC uses external providers to enhance services including the Upheal platform. Upheal empowers counselors to concentrate on their services by offering automated notes and analytics for client conversations. As a part of this process, Upheal handles protected health information for counselors, adhering to HIPAA regulations as a Business Associate.

Milestones Counseling Center PLLC has signed a Business Associate Agreement (BAA) to protect data that is shared with Upheal. Under the BAA, Upheal adheres to regulations such as the HIPAA Security Rule and Privacy Rule. This ensures that electronic health information (ePHI) is safeguarded through appropriate administrative, physical, and technical measures, ensuring its confidentiality, integrity, and security. You can learn more about Upheal and its privacy practices at www.upheal.io/privacy.

Weapons

No weapons of any kind may be brought into any Milestones Counseling Center PLLC building or office, even if otherwise allowed under state concealed carry laws, unless in the possession of a bona fide law enforcement officer. Failure to abide by this policy will result in immediate termination of services.

Termination of Services

Ending relationships can be difficult. Therefore, it is important to have a termination process to achieve closure. The appropriate length of time for termination to take place depends on many factors. Termination may take place after your goals have been achieved, progress is not being made, or a more appropriate level of care is found. Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued. You may be eligible to re-engage in services later, however appointment times/days and therapist assignments are not guaranteed.

Compliance or Ethics Concern

Quality and integrity are core values that Milestones Counseling Center PLLC. Should you ever have concerns or complaints about the quality of your care, the integrity of our billing procedures, the protection of your privacy, or our commitment to uphold the dignity and protect against the discrimination of every individual we serve, you can contact our business owner at 708-880-7747 or e-mail them at info@milestonescounselingcenter.com. All calls are confidential, may be made anonymously, and will be responded to if requested.

Acknowledgement of All Terms and Receipt of Privacy Practices

Your signature below indicates that you have carefully read all pages of this client agreement for services, as well as receive a separate copy of our Notice of Privacy Practices.

By signing, you agree to all conditions set forth in it. Please ask your therapist to address any questions or concerns that you have about this information before you sign this form.
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2025 MCC Financial Agreement & Authorization to Charge Credit Card
- All payments are ultimately the responsibility of the client. If insurance is not paying within 90 days, you will be responsible for full payment.
- All co-payments and deductible payments are due at the time of service.
- Adjustments to payment amounts from the insurance company will be applied upon receipt of the insurer’s report, without prior notification to the client.
- Full fee and sliding scale payments are due at the time of service.
- Reasonable efforts are made to verify benefits on your behalf. Please know that these benefits are subject to final approval by the insurance companies. Milestones encourages you to speak to a benefits counselor at your insurance company to fully understand your benefits.
- Insurance policies are contracts between you and your insurance company. Milestones files these claims and will assist, to a reasonable degree, with solving problems. If these attempts do not result in the completion of payment you will be asked to follow up with the insurance company.
- Any phone conversation over 7 minutes will be charged at a prorated fee based on $100/hour. This will be billed in 15 minute increments. Phone calls are not covered by your insurance company.
- Any paperwork completion over 7 minutes will be charged at a prorated fee based on $100/hour. This will be billed in 15 minute increments. Paperwork completion is not covered by your insurance company.
- Any appointments scheduled but not kept, as well as any appointments cancelled within 24 hours of scheduled time will be charged at the rate of $99. This is not covered by your insurance company.
- Milestones Counseling Center PLLC does not get involved in court proceedings. The agency will not provide documentation, aside from a treatment summary, for court purposes. If a clinician is subpoenaed, by a judge, to attend court, the client and/or their guardian is responsible to pay the court fees. Fees for court as follows: $2500 per clinician/per day, $300/hour for preparation time, any incurred legal costs for consultation required to prepare for court, and any additional fees that may be incurred due to the court participation. Please note that provisionally licensed clinicians may require, per Milestones Counseling Center PLLC, supervisory support for any and/or all of these tasks. If that support is required, fees will be doubled.
- Copays, coinsurance and session fees for non-insurance clients are due at the time services are rendered. The credit or debit card you have placed on file, if required, will be charged the day of your scheduled session. In the event that your card is declined, our office will continue to attempt to process your card including partial amounts at our discretion for up to 180 days after your appointment. We are not responsible for fees associated with the bank account, including overdraft fees, or delayed processing of your credit card.
- In the event the client contests a valid charge resulting in a reversal or chargeback initiated by their card issuer, Milestone Counseling Center PLLC will assess a clients account $50 to cover the cost charged by our credit card processor and the additional labor involved with collecting their outstanding balance.
- Failure to pay any fees within 60 days of the date of service will result in your private information being turned over to the law firm or collection agency of our choice for collection actions, including the possible filing of a public lawsuit for collections. This may result in the disclosure of some aspects of your private health information. Fees associated with collections will be added to the balance you owe to our practice.
- I authorize Milestones Counseling Center LLC to keep my credit card information on file and charge it for incurred costs including cancelled appointments, co-pays, telephone calls, etc.
- I understand that if my credit card does not accept the charge, I will immediately make the payment to the practice.
- I understand that I may cancel this authorization at any time, but by doing so, I acknowledge that the balance owing will be due & paid in full.
- I acknowledge that credit card transactions could be linked to Protected Health Information.
- I acknowledge that it is my responsibility to keep Milestones updated on any change to my credit card information.
- I acknowledge that some payment methods such as Health Savings Accounts will not allow charges for cancelled fees, paperwork, phone calls, etc. and I will still be responsible for these charges.
- I acknowledge that this is not a complete list of fees that may be incurred during my treatment. For a more complete list see the Informed Consent. Any additional services required by the clinician or client will be discussed and a price agreed upon before rendering the services. If at any time a service is rendered without being agreed upon, it will be billed at $150/hour.
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2025 MCC Employee Assistance Program (EAP) Waiver
By signing below, I waive my right to use EAP services.

I understand that EAP services are meant to be short-term, problem-solving interventions, while therapy is a more comprehensive treatment modality.

I understand that it is my responsibility to know whether I have access to EAP services or not and that Milestones Counseling Center PLLC does not check to see if these benefits are available.

I understand that if I wish to use EAP services, all necessary information including, but not limited to, authorization number, number of sessions, and beginning and end dates of the service must be provided to Milestones Counseling Center PLLC before my initial session.

I understand that I am responsible for paying all charges incurred during treatment that are not covered by my insurance or EAP company.

* BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
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2025 MCC Insurance Attestation
- I authorize the release of any medical information necessary to process my claim and payment of benefits.
- I acknowledge that it is my responsibility to inform Milestones Counseling Center (MCC) of all health insurance plans covering the client. I confirm that I have provided accurate and complete insurance information. If there are more than two insurance plans, I understand that I must contact the office to provide the additional details.
- I attest that I am only covered by the insurance plan or plans that I have listed in my intake documents. I understand that if I don’t disclose all plans under which I am covered, faulty claim filing may occur and I may end up being financially responsible for large sums of money at a later date.
- I understand that if my insurance plan recoups fees paid to Milestones Counseling Center LLC because of unpaid insurance premiums, undisclosed secondary insurance, gaps in coverage, or other reasons that are not the fault of the practice, I am financially responsible for paying Milestones Counseling Center LLC for all money recouped. Further, I understand that Milestones Counseling Center LLC may take legal action, including collections and small claims court, if I refuse to pay.
- Copays, coinsurance and session fees for non-insurance clients are due at the time services are rendered. The credit or debit card you have placed on file, if required, will be charged the day of your scheduled session. In the event that your card is declined, our office will continue to attempt to process your card including partial amounts at our discretion after your appointment. We are not responsible for fees associated with the bank account, including overdraft fees, or delayed processing of your credit card.
- In the event the client contests a valid charge resulting in a reversal or chargeback initiated by their card issuer, Milestone Counseling Center PLLC will assess a clients account $50 to cover the cost charged by our credit card processor and the additional labor involved with collecting their outstanding balance.
- Failure to pay any fees within 60 days of the date of service will result in your private information being turned over to the law firm or collection agency of our choice for collection actions, including the possible filing of a public lawsuit for collections. This may result in the disclosure of some aspects of your private health information. Fees associated with collections will be added to the balance you owe to our practice.
- I understand that I am financially responsible for co-pays and deductible payments for my sessions. I understand and agree that these charges will be posted to the credit card on file and that I must call my insurance plan, not Milestones Counseling Center LLC, if I do not understand or agree with what my plan has and has not covered.
BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
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2025 MCC HIPAA & Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION: I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

Make sure that protected health information (“PHI”) that identifies you is kept private.
Give you this notice of my legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.

MCC can change the terms of this Notice, and such changes will apply to all information MCC has about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
- For my use in treating you.
- For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
- For my use in defending myself in legal proceedings instituted by you.
- For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
- Required by law and the use or disclosure is limited to the requirements of such law.
- Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
- Required by a coroner who is performing duties authorized by law.
- Required to help avert a serious threat to the health and safety of others.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
- For law enforcement purposes, including reporting crimes occurring on my premises.
- To coroners or medical examiners, when such individuals are performing duties authorized by law.
- For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.

Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

Marketing or promotional communications about services, groups, or events offered by Milestones Counseling Center. These communications will never include sensitive clinical information. You may opt out of receiving these communications at any time by notifying the practice in writing or by using the “unsubscribe” option provided in emails.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on January 1, 2021.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
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2025 Optional Client Permission for Helpful Emails & Updates
At Milestones Counseling Center, we believe in supporting your well-being both in and out of sessions. From time to time, we send out optional email updates designed to be helpful, supportive, and informative.
By opting in, you may receive communications that include:
- Mental health tips, tools, and seasonal self-care ideas
- Agency updates including new services, staff, events, or expanded hours
- Notices about open appointment slots or clinician availability
- Emergency closures, weather-related delays, or telehealth transitions
- Announcements for groups, workshops, or events at Milestones
- Information about local or community-based resources, events, or services that may benefit your mental health and well-being (e.g., support groups, wellness fairs, nonprofit workshops, free giveaways)
These messages will never include personal health information and are sent only occasionally. Your contact information is kept confidential and never sold or shared with outside parties. You can unsubscribe at any time.
Type a question

Yes, I give permission for Milestones Counseling Center to use my name and email address to send me occasional newsletters and updates as described above. I understand that no personal health information (PHI) will be shared and that I can opt out at any time.No, I do not wish to receive any email communications beyond what is necessary for scheduling or clinical care.

2025 MCC Counseling with Provisionally Licensed Clinician
Becoming a fully licensed clinical professional (LCSW, LCPC, LMFT) is a long process. While each license has specific requirements, a general process is completed by all. Future clinicians obtain a master’s degree in a clinically related field. During this process they complete at least one year of internship/practicum, resulting in several hundred hours of client contact and education. After graduation, they apply for a provisional license (LSW, LPC, etc.). After obtaining this license, provisionally licensed clinicians are required to work under and be supervised by a fully licensed clinician for several years. Clinical interns are currently enrolled in a master’s program and working towards their master’s degree in a counseling related field.

At Milestones Counseling Center PLLC, we have several provisionally licensed clinicians and interns providing services. All the following individuals receive direct supervision from Milestones Counseling Center PLLC’s owner Michelle L. Adams, MSW, LCSW, CADC, CODP I or Emily Page, MSW, LCSW.

Patricia Burton is a Licensed Social Worker (LSW) in the State of Illinois. Patricia received her Master of Social Work from Governors State University and is receiving supervision to obtain her LCSW (Licensed Clinical Social Worker) license.

Miguel Bautista is a Licensed Social Worker (LSW) in the State of Illinois. Miguel received his Master of Social Work from Southern Illinois University in Carbondale, IL and is receiving supervision to obtain his LCSW (Licensed Clinical Social Worker) license.

Dawn Ladislas is expecting to graduate with her second Master's Degree in Clinical Mental Health Counseling in 2026. She also has a Master's Degree in Addiction Studies.

Brianna Mitchell is currently a master’s level student at Grand Canyon University. She will be graduating in 2025 with a Master's Degree in Social Work.

Kyle Meers is currently a master's level student at Governor's State University. He will be graduating in 2026 with a Master's Degree in Clinical Psychology.

Courtney Kodat is currently a master's level student at Governor's State University. She will be graduating in 2026 with a Master's Degree in Social Work.

Imroz Kalyani is currently a master's level student at Governor's State University. He will be graduating in 2026 with a Master's Degree in Social Work.

Confidentiality: Information gathered in the sessions will be held with the same confidentiality laws of all clients at Milestones Counseling Center PLLC. Session details will be discussed with the clinician’s supervision team for the purpose of feedback and support. Exceptions to this confidentiality occur when there is suspected child/elder abuse, imminent danger to the client or others, a court order, or when a client signs a release of information.

Code of Conduct: If for any reason you have questions about counseling or are dissatisfied, you have the right to meet with your therapist and their supervisor/o, Emily Page, MSW, LCSW. Emily can be reached at 708-880-7747 or via e-mail at emily@milestonescounselingcenter.com.

Emergency Situations: You may leave a message at 708-880-7747, and your call will be returned within 48 business hours. In an emergency situation when an immediate response is necessary, please call 911 or go to the nearest emergency room for attention.

I ACKNOWLEDGE THAT IF I AM SEEING A CLINICIAN LISTED ABOVE, I UNDERSTAND WHERE THEY ARE IN THEIR JOURNEY TO BECOME A FULLY LICENSED CLINCIAN AND CONSENT TO RECEIVE CARE FROM THIS CLINCIAN.
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2025 MCC Policy Reminders
PAYING FOR SERVICES
I understand that if Milestones Counseling Center PLLC provides me with information regarding my verification of benefits, this information has been obtained, as a courtesy, from my insurance company. Milestones Counseling Center PLLC has no control over the accuracy or completeness of the information provided by my insurance provider. I acknowledge that if the information is inaccurate or incomplete, I am still fully responsible for any charges incurred.

I acknowledge that it is my responsibility to know my insurance coverage and notify Milestones Counseling Center PLLC of any changes to my insurance before the change takes place.

If my insurance lapses or later says that a service is not covered, I agree to pay the full fee for that service.

I understand that all payments are ultimately my responsibility. If insurance does not cover sessions, I will be responsible for the full session fees outlined below.

INSURANCE PROCESSING
Insurance claims are processed every day, and the amount I owe might change because of things like deductibles, co-pays, or updates to my insurance plan. I will be charged for the remaining balance that my insurance company says I owe. This charge may happen on the day of my session or when the insurance notification is received.

These rate changes are decided by my insurance company, not by Milestones Counseling Center PLLC.

HOW & WHEN TO PAY
I must pay my copay, coinsurance, or session fee the day of my appointment.

My debit or credit card on file will be charged on the day the insurance claim comes back from the insurance company. Milestones Counseling Center PLLC has no way of knowing when this may occur.

Milestones Counseling Center PLLC is not responsible for any bank fees I may get. (Overdraft fees, etc.)

FAILURE TO PAY
Per the contract that Milestones Counseling Center PLLC has with health insurance companies, they MUST make reasonable attempts to collect any unpaid fees from me. This may include sending my account to collections if not paid, in full, within 60 days.

I understand that if legal or collections actions are required, some of my health information may be shared.

Any additional fees incurred due to sending my account to collections or involving a lawyer, will be added to my balance.

SESSION COSTS
$175 - First session (or family/couples therapy)

$150 - Regular 55-minute sessions

$99 - Late cancel (less than 24 hours), No-shows, Late Arrival/Early Departures (10 minutes).

*If my insurance lapses or later says that a service is not covered, I agree to pay the full fee for that service.

APPOINTMENT CANCELLATION POLICY
If I cancel or reschedule an appointment less than 24 hours in advance, I will be charged a $99 fee.

If I do not arrive for a scheduled session, I will be charged the $99 fee.

If I am more than 10 minutes late, my session may be canceled, and I will be charged the $99 fee.

HOW TO CANCEL OR RESCHEDULE
I understand that I may cancel/reschedule my appointment in the following ways and SHOULD NOT rely on voicemails to cancel/reschedule sessions:

Cancel during a prior session.

Log into my client portal and cancel my appointment at least 24 hours in advance.

Message my clinician through the client portal.

THERAPIST FIT & REFERRALS
If I feel that my therapist is not a good fit for my needs, I may request a referral from my therapist or contact the scheduling team at 708-880-7747 or admin@milestonescounselingcenter.com.

Admin staff may reach out to me, throughout treatment, to assure that my therapist is a good fit and that therapy is meeting my needs.

I acknowledge that I have read, understand, and agree to the policies outlined above. I accept responsibility for all financial obligations and communication expectations.
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Should be Empty:

	Not Applicable or Never	Occasionallyor Minimally	Some Days or Moderately	Most Days or Significantly	Every Day or Extremely
Lost a job
At risk of losing a job
Extreme emotional reactions
Disagreements with peers
Disagreements with supervisors
Significant time off in the last month
Difficulty communicating with others
Performance issues

	Not Applicable or Never	Occasionallyor Minimally	Some Days or Moderately	Most Days or Significantly	Every Day or Extremely
Excessive or inappropriate use of internet, video games or TV
Problems keeping an acceptable appearance
Problems getting ready to leave the house
Problems getting to bed
Problems with nutrition
Problems with sleeping
Avoiding exercise
Problems keeping regular appointments with doctor/dentist
Problems keeping up with household chores

	Not Applicable or Never	Occasionallyor Minimally	Some Days or Moderately	Most Days or Significantly	Every Day or Extremely
Feeling bad about yourself
Feeling frustrated with yourself
Feeling discouraged
Not feeling happy with your life
Feeling incompetent
Unhappy with my body image

	Not Applicable or Never	Occasionallyor Minimally	Some Days or Moderately	Most Days or Significantly	Every Day or Extremely
Decreased socialization
Lack of friends
Lack of hobbies
Quit/reduced sports
Sexuality/gender concerns
Substance use experimentation
Unsafe sexual practices
Lack of motivation
Lack of needed resources

	Not Applicable or Never	Occasionallyor Minimally	Some Days or Moderately	Most Days or Significantly	Every Day or Extremely
Living above means
Credit card debt
Financially impulsive
Behind on bills
Behind on rent/mortgage
At risk of losing home
Homeless
Staying with friends
Bankruptcy

Milestones Intake Questionnaire & Consents- Parents

Client's Personal Information

Guardian Information/ Primary Emergency Contact

Second Parent and/or Emergency Contact

Support Person

Primary Insurance Information

Secondary Insurance Information

Current Concerns

Areas of Life Impact Screener

Areas of Life Screening Scores

Social History

Thank you for completing your intake questionnaire.

Screening Tools- Parent

PHQ-9

GAD-7

CATS

PEARLS

Screening Scores

2025 MCC Intake Consents- Parents

2025 MCC Informed Consent for Mental Health Services & Practice Policies

2025 MCC Financial Agreement & Authorization to Charge Credit Card

2025 MCC Employee Assistance Program (EAP) Waiver

2025 MCC Insurance Attestation

2025 MCC HIPAA & Notice of Privacy Practices

2025 Optional Client Permission for Helpful Emails & Updates

2025 MCC Counseling with Provisionally Licensed Clinician

2025 MCC Training Program Participation Consent Form

2025 MCC Policy Reminders

	Not Applicable or Never	Occasionallyor Minimally	Some Days or Moderately	Most Days or Significantly	Every Day or Extremely
Lack of healthy communication
Division of labor problems
Lacks trust
Arguments
Verbal aaggression towards partner
Physical aggression towards partner
Infidelity
Stress
Unhealthy/unsafe sexual practices
Sexually inappropriate behavior

	Not Applicable or Never	Occasionallyor Minimally	Some Days or Moderately	Most Days or Significantly	Every Day or Extremely
Aggressive driving
Doing other things while driving
Road rage
Breaking or damaging things
Doing things that are illegal
Being involved with the police
Current Legal Case

	Not Applicable or Never	Occasionallyor Minimally	Some Days or Moderately	Most Days or Significantly	Every Day or Extremely
Tardiness
Skipping classes
Disrespecting staff
Acting out
Sleeping in class
Difficulty with school work/homework
Bullying others
Being bullied
Fighting/ Aggressive behavior
Posessing a weapon
Detention
At risk of expulsion
Expelled

	Not Applicable or Never	Occasionallyor Minimally	Some Days or Moderately	Most Days or Significantly	Every Day or Extremely
Lack of healthy communication
Not meeting their needs
Lacks trust
Verbal aggression
Physical aggression
Inappropriate boundaries

	Not at all	Several Days	More than half the days	Nearly every day
Feeling down, depressed, irritable, or hopeless?
Little interest or pleasure in doing things?
Trouble falling or staying asleep, sleeping too much
Poor appetite, weight loss, or overeating?
Feeling tired, or having little energy?
Feeling bad about yourself – or feeling that you are a failure, or that you have let yourself or your family down?
Trouble concentrating on things like school work, reading, or watching TV?
Moving or speaking so slowly that otherpeople could have noticed? Or the opposite – being so fidgety or restless that you were moving around a lot more than usual?
Thoughts that you would be better off dead, or of hurting yourself in some way?

	Not at all	Several Days	More than half the days	Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

	Never	Once in a While	Half the Time	Almost Always
Upsetting thoughts or pictures about what happened that pop into your head.
Bad dreams reminding you of what happened.
Feeling very upset when you are reminded of what happened.
Feeling very upset when something reminded you of the stressful experience?
Strong feelings in your body when you are reminded of what happened (sweating, heart beating fast, upset stomach).
Trying not to think about what happened. Or to not have feelings about it.
Staying away from anything that reminds you of what happened (people, places, things, situations, talks).
Not being able to remember part of what happened.
Negative thoughts about yourself or others. Thoughts like I won’t have a good life, no one can be trusted, the whole world is unsafe.
Blaming yourself for what happened. Or blaming someone else when it isn’t their fault.
Bad feelings (afraid, angry, guilty, ashamed) a lot of the time.
Not wanting to do things you used to do.
Not feeling close to people.
Not being able to have good or happy feelings.
Feeling mad. Having fits of anger and taking it out on others.
Doing unsafe things.
Being overly careful (checking to see who is around you).
Being jumpy.
Problems paying attention.
Trouble falling or staying asleep.

	Yes	No
Have you ever lived with a parent/caregiver who went to jail/prison?
Have you ever felt unsupported, unloved and/or unprotected?
Have you ever lived with a parent/caregiver who had mental health issues? (for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)
Has a parent/caregiver ever insulted, humiliated, or put you down?
Has your biological parent or any caregiver ever had, or currently has a problem with too much alcohol, street drugs or prescription medications use?
Have you ever lacked appropriate care by any caregiver? (for example, not being protected from unsafe situations, or not being cared for when sick or injured even when the resources were available)
Have you ever seen or heard a parent/caregiver being screamed at, sworn at, insulted or humiliated by another adult? Or have you ever seen or heard a parent/caregiver being slapped, kicked, punched beaten up or hurt with a weapon?
Has any adult in the household often or very often pushed, grabbed, slapped or thrown something at you? Or has any adult in the household ever hit you so hard that you had marks or were injured? Or has any adult in the household ever threatened you or acted in a way that made you afraid that you might be hurt?
Have you ever experienced sexual abuse? (for example, has anyone touched you or asked you to touch that person in a way that was unwanted, or made you feel uncomfortable)
Have there ever been significant changes in the relationship status of your caregiver(s)? (for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in or out)

	Yes	No
Have you ever seen, heard, or been a victim of violence in your neighborhood, community or school? (for example, targeted bullying, assault or other violent actions, war or terrorism)
Have you experienced discrimination? (for example, being hassled or made to feel inferior or excluded because of their race, ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)
Have you ever had problems with housing? (for example, being homeless, not having a stable place to live, moved more than two times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members)
Have you ever worried that you did not have enough food to eat or that food would run out before you or your parent/caregiver could buy more?
Have you ever been separated from your parent or caregiver due to foster care, or immigration?
Have you ever lived with a parent/caregiver who had a serious physical illness or disability?
Have you ever lived with a parent or caregiver who died?
Have you ever been detained, arrested or incarcerated?
Have you ever experienced verbal or physical abuse or threats from a romantic partners? (for example, a boyfriend or girlfriend)