Are you seeking counseling services under any of the following: *
Required
Name of Person Completing this Form: *
Your answer
Name of Client (if different from above) or NA: *
Your answer
What type of therapy are you seeking? *
Client date of birth: *
Your answer
Phone: *
Your answer
Can a Voicemail be left on the phone number provided: *
Required
Private Email Address that can be used for Follow Up: *
Your answer
Preferred method of communication: *
Address on file with insurance (for insurance verification) *
Your answer
Primary Insurance Carrier Name - (For HMO plans, include the site affiliation (AMITA, Duly, Edwards/Elmhurst, Loyola, RUSH, etc.)) Or Identify as Self-Pay. *
Your answer
Do you have a secondary insurance policy? *
Insurance/s Member ID number with 3 Alpha Prefix (of client): *
Your answer
Insurance Group number (of client): *
Your answer
Is this an HMO or PPO policy *
Gender listed on Insurance *
Are you currently living in Illinois? Please note we are only licensed in Illinois. Anyone residing outside IL can only be seen six times by our clinical team. *
Identify your top 3 choices in order of preference:
First Choice
Second Choice
Third Choice
Riverside In-Person limited availability
Oak Brook In-Person
Westmont In-Person
Lombard In-Person
Chicago In-Person
Telehealth
First Choice
Second Choice
Third Choice
Riverside In-Person limited availability
Oak Brook In-Person
Westmont In-Person
Lombard In-Person
Chicago In-Person
Telehealth
Clear selection
Availability for ongoing therapy appointments (select all that apply): *
Required
Preferred Identification of Clinician: *
Clinician Specialty (examples such as couples, individual, christianing, parenting, Spanish speaking, anxiety, depression, etc.): *
Your answer
Referred by (if you have a doctor's referral, please include your doctor's name):
Your answer
Reason for requested counseling at this time, please be as detailed as you can: *
Your answer
Have you been seen by a mental health professional before? *