One who knows others is wise. One who knows self is enlightened.

Tao Te Ching


Michael Schneider, Ph.D.

Clinical Psychologist

Licensed to Practice in Illinois and Missouri





Please click on the highlighted hyperlink to view the form.  

[Note: Word for Windows is required to open each (Word.doc), and Adobe Reader is required to open each (.pdf file).]

The Insurance Data form (Word .doc) (.pdf file) shows the information normally collected so that insurance companies can be billed for services.  You do not need to supply your social security number if your insurance plan now uses a different client number.  Also please note that most insurance companies require that you be given a psychiatric diagnosis before they will reimburse you for services.  If you do not wish to have a diagnosis in their records you may wish to explore other payment options.

The Service Consent form (Word .doc) (.pdf file) simply indicates that you have read, understood and agreed to my Confidentiality and Privacy policy, Emergency policy, and have agreed upon a fee for services.  Finally, it indicates that you have voluntarily agreed to receive services from me.

The Release of Information form (Word .doc) (.pdf file) is here to show you that you have a right to know what specific information is being requested from another party (or released to another party) and for what purpose.  You have a legal right to refuse to disclose any information related to HIV or alcohol issues.  Every signed release also has an expiration date and you can cancel the release before that date if you wish.

The Intake Form (Word .doc) (.pdf file) is provided here to give you an idea of what kind of information is reviewed during the initial assessment.  While it may seem overly complex at first, keep in mind that I wish to view you as a whole person, not as a "problem".  Who we are today is the product of many influences.  Who we are tomorrow will be determined by how we choose to think and act and feel.  It sometimes helps to take a look at where you are starting from so that you can figure out how to get to where  you want to be.


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