Request an Appointment / Make a Referral

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Please fill out the following information. We will check your benefits and connect you with a therapist.

An email response for all requests and inquiries will come to you from a member of our intake team at info@mindbodycoopchicago.com within 24 hours. If you do not receive an email response during that time frame, please check your spam and/or junk mail folders. If we do not hear back from you within a week, we will then call the number you supplied.

Email *

First Name: *

Last Name: *

Living Name (if different than legal name above):

Pronouns:

Age: *

Phone Number: *

Can we call or text you? *

Yes

Can we email you? *

Yes

Preferred Language: *

(اللغة العربية) Arabic

English

Spanish (Español)

Polish

If you are seeking services that are provided by Licensed Clinical Professional Counselors, Licensed Clinical Social Workers or Psychiatric Nurse Practitioners, please check the box confirming that you live in Illinois. Do you currently reside in Illinois? *

Yes

Required

Current Zip Code *

Individual Healing Options: *

Psychotherapy

Medication Management/Psychiatric Support

Neuropsychological Evaluation and/or Psychological Evaluation & Assessment

EMDR- Eye Movement Desensitization and Reprocessing

TMS- Transcranial Magnetic Stimulation

Massage Therapy

Acupuncture

Nutrition/Dietitian Counseling Support

Required

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