APPOINTMENT REQUEST
Samaritan Counseling Center of the Northwest Suburbs
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Please Select
Cook
Lake
McHenry
Kane
Other
Email
example@example.com
Phone Number
Please enter a valid phone number.
Client's Name (if different from above)
First Name
Last Name
Birth Date
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1921
1920
Year
Insurance
Please Select
Blue Cross / Blue Shield PPO
Aetna PPO
Cigna PPO
United PPO
Medicare
Meridian
Other
Member ID
Group #
Insurance Phone #
Please enter a valid phone number.
Name of Insurance Policy Holder
First Name
Last Name
Date of Birth for Insurance Policy Holder
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
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5
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31
Day
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
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1988
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1984
1983
1982
1981
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1953
1952
1951
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1949
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1947
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1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
If EAP, Name of EAP
EAP Phone #
Please enter a valid phone number.
Employer
Employer Phone #
Please enter a valid phone number.
EAP Authorization Code
Reason For Counseling (e.g., anxiety, depression, stress, etc.)
Availability
Please Select
Weekday mornings
Weekday afternoons
Weekday evenings
Flexible
Submit
Should be Empty: