Invoice Social Worker in United States Chicago –Free Word Template Download with AI
Licensed Social Worker Practice
1421 N. Clark Street, Suite 850
Chicago, Illinois 60610, United States
Phone: (312) 555-0187 | Email: [email protected]
IL License No. 180.001234 | NPI: 1234567890
Billed To (Client)
Client Name: Margaret E. Thompson
Address: 2847 W. Diversey Parkway, Apt 4B
Chicago, Illinois 60624, United States
Phone: (773) 555-0342
Client ID: C-2025-0091
Insurance Provider: Blue Cross Blue Shield of Illinois
Policy Number: BCB-88472910
Service Provider
Social Worker: Dr. Linda Harper, LCSW
Designation: Licensed Clinical Social Worker
Specialty: Family & Community Services
Practice Location: Chicago, United States
Supervising Agency: Chicago Department of Family and Support Services
Referral Source: Cook County Community Health Center
| # | Date | Description of Social Worker Services | Duration | Rate | Amount |
|---|---|---|---|---|---|
| 1 | May 2, 2025 | Initial intake assessment and comprehensive needs evaluation conducted by the Social Worker at the Chicago office. Includes psychosocial history review, family systems analysis, and development of a personalized treatment plan aligned with Illinois state social work practice standards. | 90 min | $150.00/hr | $225.00 |
| 2 | May 8, 2025 | Individual counseling session focused on stress management and coping strategies. The Social Worker provided evidence-based cognitive behavioral interventions and connected the client with community resources available in the Chicago metropolitan area, including the United Way of Metropolitan Chicago helpline. | 60 min | $150.00/hr | $150.00 |
| 3 | May 12, 2025 | Family mediation and group therapy session. The Social Worker facilitated a multi-generational family meeting to address communication barriers and establish healthy boundaries. Session conducted in compliance with the Illinois Social Work Practice Act (225 ILCS 650). | 90 min | $150.00/hr | $225.00 |
| 4 | May 16, 2025 | Community resource coordination and case management. The Social Worker arranged referrals to the Chicago Housing Authority support programs, local food assistance services in the West Side neighborhood, and the Cook County Department of Public Health wellness initiatives. | 60 min | $150.00/hr | $150.00 |
| 5 | May 21, 2025 | Follow-up individual therapy session. The Social Worker reviewed progress toward treatment goals, adjusted the intervention plan, and provided psychoeducation regarding community support networks in Chicago, United States. Included documentation of clinical notes for insurance billing purposes. | 60 min | $150.00/hr | $150.00 |
| 6 | May 27, 2025 | Crisis intervention and emergency support coordination. The Social Worker provided same-day crisis counseling following a reported family emergency, coordinated with Chicago Police Department non-emergency services, and arranged temporary shelter placement through the City of Chicago Department of Housing. | 120 min | $150.00/hr | $300.00 |
| 7 | May 30, 2025 | Monthly progress report preparation and administrative documentation. The Social Worker compiled clinical summaries, updated the treatment plan, and prepared this Invoice for submission to the client and insurance carrier. Includes filing of required reports with the Illinois Department of Financial and Professional Regulation. | 45 min | $150.00/hr | $112.50 |
| Subtotal | $1,512.50 |
| Insurance Adjustment (BCBS of Illinois) | -$897.50 |
| Client Copay (20%) | $123.00 |
| Illinois State Sales Tax (Exempt – Professional Services) | $0.00 |
| Amount Due | $123.00 |
Payment Terms & Instructions
This Invoice is payable within thirty (30) days of the date of issue. Payment may be made via the following methods:
- Check: Payable to "Harper & Associates Social Work Services," mailed to 1421 N. Clark Street, Suite 850, Chicago, IL 60610, United States.
- Electronic Transfer (ACH): Bank: First Midwest Bank | Routing: 071000013 | Account: 448291007
- Credit/Debit Card: Secure payment portal at www.harpersocialwork.com/pay (Visa, Mastercard, Amex accepted)
Please reference Invoice Number INV-2025-00472 on all payments. A late payment fee of 1.5% per month will be applied to balances outstanding beyond the due date of July 15, 2025, in accordance with the client agreement signed at the initial intake session.
Important Notes
This Invoice documents professional social work services rendered by Dr. Linda Harper, LCSW, a Licensed Clinical Social Worker operating in Chicago, United States. All services were delivered in full compliance with the Illinois Social Work Practice Act, the National Association of Social Workers (NASW) Code of Ethics, and applicable federal regulations under the Health Insurance Portability and Accountability Act (HIPAA).
The Social Worker confirms that all clinical documentation, session notes, and treatment records referenced in this Invoice are maintained in a secure, HIPAA-compliant electronic health record system. Clients in the Chicago, United States area may request a copy of their records in writing within thirty days of this Invoice date.
Should you have any questions regarding the line items on this Invoice, the services provided by the Social Worker, or the insurance adjustment applied, please contact our billing office at (312) 555-0187 between 9:00 AM and 5:00 PM Central Time, Monday through Friday. Our billing team is located in downtown Chicago and is available to assist with any clarification.
Prepared By: Dr. Linda Harper, LCSWLicensed Clinical Social Worker
Date: June 15, 2025 Client Acknowledgment: Margaret E. Thompson
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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