Please find forms below
IPD requires that an IPD Authorization to Release Information form be completed by the patient prior to our releasing, or requesting, medical records on the patient’s behalf.
Please select, print and complete this authorization form.
There are three very important items that must be done to complete the form.
- Please sign and date the form where it says “signature of client.”
- A witness MUST be present when the form is signed and that witness MUST sign the form and date it for it to be valid. Have the witness sign it where it says “signature of witness.”
- Write in the line after “for the purpose of:” the reason why medical records are being requested.
For your convenience, you can fax the signed authorization to IPD’s confidential medical records fax number:
**There is a standard processing fee of $30.00 for any medical records that are released**
What is qEEG?
A Quantitative EEG (qEEG) is a painless, diagnostic test that records the electrical activity of your brain. It has no side-effects and is useful for determining brain related conditions such as attention disorders, anxiety, depression, stroke, tumor, head injury, memory difficulties and seizures. During your appointment, the technologist will measure your head and use a sticky paste to apply 21 sensors, called electrodes, to your scalp, an electrode to each ear lobe, and one electrode to your chest for recording your heartbeat. Throughout the test, the room will be in partial darkness and you will sit quietly in a comfortable chair. At times you will rest with your eyes closed, and at other times, your eyes will be open. We will also record while you use a laptop to interact with some computer-generated sounds and shapes. Next, you will be asked to do some deep breathing for about three minutes, and lastly, you will rest in the recliner with your eyes closed for about twenty minutes. During that time, we would like you to be comfortable and relaxed, and if possible, take a brief nap. When the testing is complete, the technologist will remove the electrodes and try to remove most of the paste. At home, any remaining paste can be removed by shampooing with warm water. It will take about ten day to analyze your data and write a report, so please schedule your follow-up appointment to discuss your results after that time. This information will aid in development of appropriate interventions that are tailored to your needs. If you have any other questions, please feel free to call the office or ask your technologist before the test. Thank you.
IPD provides services that are individualized for each and every client. Our clinicians are highly trained and focus on a thorough evaluation of the cause of your emotional pain. We examine problems in an individual’s relationships, job and life. We will understand the environment in which they grew up and how this may have effected how they view the world. We understand the value system which they hold dear. We evaluate if they are on medications which could make them feel bad, if they might have a medical disorder which effects how they feel or if they have a brain chemistry problem which is causing them to feel bad and distort the way they see and experience the world. Once a thorough evaluation is completed a treatment plan is designed and discussed with the individual and (with the patients permission) the family. We identify treatments which are scientifically proven to be effective in the condition or conditions which you have presented and then we “get to work”.
It is important to us that you OBTAIN RESULTS AND IMPROVE YOUR QUALITY OF LIFE! Our goal is to assist with alleviating emotional pain and suffering for individuals, families and communities. Our plan for treatment is to improve each individual’s quality of life. Within treatment, we use traditional and complementary approaches with the highest level of clinical and ethical standards.
This varies on the doctor you are seeing. Some doctors are scheduled more solidly than others and emergencies can come up which may alter a doctor’s schedule. It is recommended that you schedule your appointments with as much notice as possible to get the date and time that is good for you.
During the day you may call 815-942-6323 Press 5 and leave a message for your clinician. Please convey the nature of the problem to help your clinician understand the level of urgency of your concern.
After hours if there is an urgent issue and you need to contact your doctor or clinician you may call our answering service at 888-549-3197 and ask your doctor or clinician to be paged.
If you have a clinical matter you wish to discuss with your clinician, we suggest that you call to make an appointment to see your clinician as soon as possible. You can ask the secretary, if there is not an immediate appointment available, if you could get in on an emergency visit with our Nurse Practitioner who can directly get input from your clinician as to how to proceed.
During office hours our doctors are always seeing patients, in most cases you will need to leave a message and the doctor will return your call as soon as possible. If it is an emergency our staff will alert the doctor right away. Keep in mind that doctors may charge for phone consultations, insurance does not cover this charge.
If there is an emergency please call 911 or go to the nearest emergency room. The emergency room physician can contact our doctors through the answering service 888-549-3197.
You can call the office and request refills over the phone. Refill requests can take up to 48 hours to be completed.
We accept the following insurance:
Behavioral Health Systems
Blue Choice PPO
ERC (Fox Valley & Northwest)
Humana / Lifesynch
Rail Road Medicare
MHN / Tricare
Mutual of Omaha
Multi Plan/ PHCS
Health Smart, 1st Health
United Behavioral Health / UMR / Optum
Please refer to your insurer’s explanation of benefits (EOB), which explains how payments and adjustments were made.
For questions about your bill, please contact MaryJane at: (815) 942-6323 Press 2.
This is often because the insurance company has applied this amount to your deductible. Please refer to your insurance EOB or call your insruance company to be sure.
No. Insurance companies almost never pay for such charges.
Med Loan Finance is one of the finest medical finance companies that is dedicated to finding the perfect fit for our customers needs. We work with people of all credit histories and backgrounds, and our extensive base of lenders and providers make it possible to offer the best medical financing around.
More Approvals, More Options
Amounts from $500 to $100,000 / Lowest Interest Rates Available* / 6-21 Months Interest Free* / No Pre-Payment Penalty* * Depends on Applicants Credit and Lendor Financing for Behavioral Health Treatment is available!
Med Loans dedicated team of agents comes with years of experience, which means they know how to leverage lending companies to get the most competitive rates. Many of our customers enjoy options for no-money down, as well as interest free medical options for 12-21 months. Even those with average credit are often able to enjoy interest free options as well as no-money down, and those with poor credit are generally approved on an appropriate program that offers competitive rates.
Med Loan Finance wants to help people who care about their health, which is why they strive to provide the financial tools to help pay medical bills. To get started with one of their interest free loans, fill out our online application that takes just minutes to complete. Then you will be directed to our Loan Search Form that has different options for you to select from including the Interest Free periods and payments as low as 1% of your balance. Then within 1 business day we will notify you of options that we may have obtained for you.
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The following books and references are recommended.
Death and Greiving
“Final gifts: Understanding the Special Awareness, Needs, and Communications of the Dying” by Maggie Callanan
“Tuesdays with Morrie: An Old Man, a Young Man, and Life’s Greatest Lesson” by Mitch Albom
“Conquering the Mysteries and Lies of Grief” by Sherry Russell
“How to Survive the Loss of a Love” by Peter McWilliams
“Sad Isn’t Bad: A Good-Grief Guidebook for Kids Dealing With Loss (Elf-Help Books for Kids)” by Michaelene Mundy
“I Wasn’t Ready to Say Goodbye” by Brook Noel
“The Tibetan Book of Living and Dying: The Spiritual Classic &
International Bestseller; Revised and Updated Edition” by Sogval
“Good Grief: A Constructive Approach to the Problem of Loss” by Granger E. Westberg
“On Death and Dying” by Elisabeth Kubler-Ross
“A Grief Observed” by C.S. Lewis
“Healing After Loss: Daily Meditations For Working Through Grief” by Martha Whitmore Hickman
“The Grief Recovery Handbook: The Action Program for Moving Beyond Death Divorce, and Other Losses” by John W. James
“Embraced by the Light” by Betty J. Eadie
“How To Go On Living When Someone You Love Dies” by Therese A. Rando
“Where’s God When It Hurts?” by Philip Yancey
“How We Die: Reflections on Life’s Final Chapter” by Sherwin B. Nuland
“Silver Linings: Triumph of the Challenger 7″ by June Scobee Rodgers
“Tear Soup” by Pat Schweibert
“C.S. Lewis Signature Classics: Mere Christianity, The Screwtape
Letters, A Grief Observed, The Problem of Pain, Miracles, and The Great
Divorce (Boxed Set)” by C.S. Lewis
“What On Earth Do You Do When Someone Dies?” by Trevor Romain
“The Easy Way to Stop Smoking: Join the Millions Who Have Become Nonsmokers Using the Easyway Method” by Allen Carr (Hardcover – Jan 2005)
“The Alcoholism and Addiction Cure: A Holistic Approach to Total Recovery” by Chris Prentiss (Paperback – Sep 2005)
“Beautiful Boy: A Father’s Journey Through His Son’s Meth Addiction” by David Sheff (Hardcover – Feb 26, 2008)”
Save Me from Myself: How I Found God, Quit Korn, Kicked Drugs, and Lived to Tell My Story” by Brian “Head” Welch (Hardcover – Jul 3, 2007)
“Alcoholics Anonymous: Big Book”, Original Edition (Hardcover – Jul 26, 2007)
“Adult Children of Alcoholics” by Janet G. Woititz (Paperback – Nov 1, 1990)
“Codependents’ Guide to the Twelve Steps” by Melody Beattie (Paperback – April 9, 1992)
“Narcotics Anonymous” by Narcotics Anonymous (Hardcover – Dec 1, 1991)
“Courage to Change: One Day at a Time in Al-Anon II” by Al-Anon Family Group Head Inc (Hardcover – Jun 1992)”
Twelve Steps and Twelve Traditions” by Alcoholics Anonymous (Hardcover – Feb 10, 2002)
“Drinking: A Love Story” by Caroline Knapp (Paperback – May 12, 1997)”
Freedom from Addiction: The Chopra Center Method for Overcoming Destructive Habits” by Deepak Chopra and M.D., David Simon (Paperback – Nov 1, 2007)
“Broken” by William Cope Moyers (Paperback – Aug 28, 2007)
“Drug Information Handbook” by Charles F. Lacy, Leonard L. Lance, Lora L. Armstrong, and Naomi B. Ingrim (Paperback – Jul 1998)
“Love First: A New Approach to Intervention for Alcoholism and Drug Addiction (A Hazelden Guidebook)” by Jeff Jay and Debra Jay
“Twelve Steps and Twelve Traditions” by AA Services (Paperback – Feb 10, 2002)
“A Gentle Path Through the Twelve Steps: The Classic Guide for All People in the Process of Recovery” by Ph.D., Patrick Carnes (Paperback – Sep 1, 1994”
It Will Never Happen to Me: Growing Up With Addiction As Youngsters, Adolescents, Adults” by Claudia Black (Paperback – Mar 8, 2002)
“Living Sober” by AA Services (Paperback – Feb 10, 2002)
“A Woman’s Way Through the Twelve Steps Workbook” by Stephanie S. Covington Ph. D. (Paperback – Oct 1, 2000)”
Under the Influence: A Guide to the Myths and Realities of Alcoholism” by James Robert Milam and Katherine Ketcham (Paperback – Jun 1, 1984)
“Uppers, Downers, All Arounders: Physical and Mental Effects of Psychoactive Drugs” by Darryl Inaba (Paperback – Jul 2000)
“The Complete ACOA Sourcebook: Adult Children of Alcoholics at Home, at Work and in Love” by Janet Woititz and Robert Ackerman (Paperback – Mar 8, 2002)
“Addiction: Why Can’t They Just Stop?” by Susan Cheever, John Hoffman, Susan Froemke, and Sheila Nevins (Hardcover – Mar 6, 2007)
“Drugs, Society, and Human Behavior, 12th Edition” by Charles J. Ksir, Carl L Hart, and Oakley S Ray (Paperback – Nov 2006)
“Addict In The Family: Stories of Loss, Hope, and Recovery” by Beverly Conyers (Paperback – Aug 26, 2003)
“Dopefiend” by Donald Goines (Mass Market Paperback – May 31, 2007)
The Straight Facts about the Most Used and Abused Drugs from Alcohol to
Ecstasy, Fully Revised and Updated Second Edition” by Cynthia Kuhn, Scott, Ph.D. Swartzwelder, Wilkie, Ph.D. Wilson, and Leigh Heather Wilson (Paperback – Oct 2003)
“Relapse Prevention Counseling Workbook: Managing High-Risk Situations” by Terence T. Gorski (Paperback – May 1996)
“Recovery: A Guide for Adult Children of Alcoholics” by Herbert L. Gravitz and Julie D. Bowden (Paperback – Sep 15, 1987)
“Feeling Good: The New Mood Therapy”
“The Noonday Demon: An Atlas of Depression”
“You Can Be Happy No Matter What”
“Feel the Fear and Do It Anyway”
“You Can Heal Your Life”
“An Unquiet Mind”
“Ten Days to Self-Esteem”
The “Elf-Help” Books