CWHC Counseling Contact Request Form
Thank you for your interest in counseling at CWHC. At this time, we have limited availability to add new counseling clients. Please complete this form and we will contact you at the phone number or email address you provide. Please be sure to include specific days and times when you are available for counseling. If we do not have availability that matches your needs, we will be happy to offer you referrals to other counseling programs. 

We will do our best to respond to your request within one week. If you have already completed this form or reached out and left us a voicemail at 773-935-6126, ext. 200, please do not create a duplicate request as we will return your message in the order we received it. 

This form is NOT intended for immediate or crisis services. If this is an emergency, please consider calling 988 or going to your nearest emergency room. There are also crisis lines available if you need to speak to a mental health professional or advocate immediately: for Crisis Hotlines in the Chicago area, you may call NAMI Chicago’s Helpline at 833-626-4244 or follow this link https://www.namichicago.org/resources. 

For a list of alternatives to calling police in the Chicago area, please follow this link for resources via Don't Call the Police - Chicago: https://dontcallthepolice.com/chicago/. 

We look forward to connecting with you.

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What is your first/preferred name? *
What are your pronouns?
Please provide your phone number.  *
Please provide your email address. *
Is it okay for us to leave a detailed voicemail and/or email message? *
What would you like to learn more about from the Counseling team at Chicago Women's Health Center? *
Required
Are you a current CWHC client? If yes, in which program(s)? *
Required
Would you like to use your insurance or use out-of-pocket sliding scale options for counseling services? (Currently CWHC is only in network with BCBS PPO. Unfortunately we do not accept Medicaid/Medicare.)
If you will be using BCBS PPO, please provide your member number (aka ID number) and group number (if listed).
What are some specific days and times when you are available for 50-minute counseling sessions (Mon-Fri 9am-7pm)? *
Briefly, what brings you to counseling right now?
What personal identities or life experiences do you want to us to know about you before you start counseling?
What identities, qualities or skills are you looking for in a counselor? (This is to help us find the best match for you, and we may not be able to fulfill all preferences.)
Any other comments, questions or concerns?
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